Download with criteria- March 2016

CATEGORY
Coverage
Step Order
Indicator
PREFERRED DRUGS
Coverage
Indicator
Step
Order
NON-PREFERRED DRUGS
Required
PA
Comments
Criteria
* PLEASE NOTE: All cost effective generics applicable to DEL are considered PREFERRED Drugs. "BASIC" Covered Drugs are bolded with the Coverage Indicator of "MC / DEL".
General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet: www.mainecarepdl.org
A: Preferred Drugs- Unless otherwise specified, preferred drugs are available without prior authorization. Step order may apply for preferred drugs in some drug categories as indicated on the PDL. (See item "D" below for explanation of step order.)
B: Requests for Non-preferred Drugs- Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists.
C: Adequate Drug Trials- 1. The minimum trial period for each preferred and step order drug is two weeks, unless otherwise stated within specific PDL drug categories; trials with less than a two week duration will be reviewed on a case-by-case basis; 2. A trial will not be considered valid if preferred or non-preferred products were readily available (by override, individual purchase, samples,
etc.); 3. Certain drug trials, such as with controlled substances, may require evidence that the preferred drugs were actually tried (example: with random pill counts and with random urine drug tests, using the methods of GC/MS with no lower threshold); 4. Adequate trials require documentation of attempts to titrate dose of preferred agents toward desired clinical response. 5. Adequate trials
include prevention/treatment of common adverse effects associated with preferred agents (example: antinausea, antipruritics, etc.)
D: Step Order- When numbers appear in the "step order" column, it means drugs in this category must be used in the order specified, with the lower numbers having preference over the higher numbers. Chart notes should be provided to confirm drug trials that do not appear in the member's MaineCare drug profile.
E. The Department will institute strategies to ensure cost effectiveness through the use of an enhanced Drug Benefit Preferred brand drugs will no longer be preferred in any PDL drug category where preferred generic drugs are also available. It is expected that preferred generics will be used prior to any preferred brands. This will be operated as a form of step care. Preferred brands in these
categories will require prior authorization for these high utilization / high cost members.
F: Brand Name Medication Requests- (Must be submitted on the Brand Name PA request form)- According to MaineCare Benefits Manual Chapter II (80.07-5), when medically necessary covered brand-name drugs have an A-rated generic equivalent available, the most cost effective medically necessary version will be approved and reimbursed, since the brand-name and A-rated generic drugs
have been determined by the FDA to be chemically and therapeutically equivalent. The Bureau does not make determinations as to whether or not a generic drug is clinically inferior or inequivalent to its brand version. This is the proper role of the FDA. Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH.
G: PA requests for non- FDA Approved Indications- Decisions will be made on a case-by-case basis until the DUR committee is able to review the evidence and make a recommendation. Interim approvals and DUR recommendations for approval of a drug for a non- FDA approved indication will require a minimum of two published, peer reviewed, non contradicted, double- blind, placebocontrolled randomized clinical studies establishing both safety and efficacy.
H: Dose Consolidation Requirements- Some drugs may also be affected by dose consolidation requirements. Please see Dose Consolidation List and/or Splitting Tables provided in the PDL.
I. Trials from Multiple Drug Classes - Trial/failure/intolerance to preferred agents from multiple classes within the same category or other catagories of drugs may be required prior to the approval of non-preferred agents (e.g., Cymbalta, Zofran, Elidel and others).
J. Drug-specific PA Forms- Drug-specific PA forms contain medical necessity documentation requirements and/or criteria that may not be repeated in the PDL. Drug-specific PA forms may be obtained on the web at www.mainecarepdl.org .
K. PA Exemptions for Prescribers- According to MaineCare Benefits Manual Chapter II (80.07-4), providers may receive a three (3) month exemption from prior authorization requirement for certain categories of drugs when they demonstrate high compliance with the Department's PDL. The Department will notify providers in writing which drug categories are included and what dates apply to the
exemption. If a provider loses his/ her exemption, members who previously were not required to obtain a PA while the prescriber was exempt will be required to do so, and criteria for approval of that medication will need to be met.
L: Drug-Drug Interactions (DDI)- The DUR Committee has implemented new drug-drug interation edits requiring prior authorization. Several drug-drug combinations and PDL drug catagories are affected by new PA requirements. These will be indicated in the PDL with DDI notation. Please see the DDI document provided in the PDL.
ASSORTED ANTIBIOTICS
BETA-LACTAMS / CLAVULANATE
COMBO'S
MC/DEL
AMOXICILLIN
MC/DEL
AUGMENTIN3
MC/DEL
AMOXICILLIN/POTASSIUM CLA CHEW
MC/DEL
AUGMENTIN XR TB124
MC/DEL
AMOXICILLIN/POTASSIUM CLA SUSR
MC/DEL
AMOXICILLIN/POTASSIUM CLA TABS
MC/DEL
AMPICILLIN
MC
MC/DEL
CEPHALOSPORINS
BICILLIN L-A SUSP
4. Use preferred generic
amoxicillin/clavulanate
potassium alternatives.
DICLOXACILLIN SODIUM CAPS
MC
OXACILLIN SODIUM SOLR
MC/DEL
PENICILLIN V POTASSIUM
MC
TIMENTIN SOLR
MC
UNASYN SOLR
ZOSYN
MC/DEL
CEFADROXIL HEMIHYDRATE
MC/DEL
CEFAZOLIN SODIUM SOLR
MC/DEL
MC/DEL
CEFDINIR
MC/DEL
MC/DEL
CEFEPIME
MC/DEL
MC/DEL
CEFPODOXIME
MC/DEL
CEFTIN
FORTAZ
MC/DEL
CEFPROZIL
MC/DEL
FORTAZ SOLN
MC
CEDAX
CEFACLOR1
CEFADROXIL MONOHYDRATE TABS
CEFTAZIDIME 6MG
MC
KEFLEX CAPS
MC/DEL
CEFTIN SUSP
MC
OMNICEF
MC/DEL
CEFTRIAXONE
MC/DEL
ROCEPHIN
MC/DEL
CEFUROXIME AXETIL TABS
MC/DEL
CEPHALEXIN MONOHYDRATE
MC
DDI: Ampicillin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently non
preferred PPI.
Use PA Form# 20420
MC/DEL
MC
3. Chewable 125mg &
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
250mg and Solution
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
125mg/5ml and 250mg/5ml preferred drug(s) exists.
available without PA.
MC
MC/DEL
1. Both brand and generic Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
are clinically non-preferred. on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Dosing limits apply,
please see Dosage
Consolidation List.
TAZICEF SOLR
Suprex will be preferred with dosing limits of one tablet per 7days for prevention and treatment of STI gonorrhoea.
DDI: Vantin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently non
preferred PPI.
TEFLARO
FORTAZ SOLR
Page 1 of 58
MC/DEL
MC
MACROLIDES / ERYTHROMYCIN'S
2
SUPRAX
TAZICEF 6GM
Use PA Form# 20420
MC/DEL
AZITHROMYCIN TABS
MC/DEL
MC/DEL
AZITHROMYCIN SUSP
MC/DEL
AZITHROMYCIN POW
CLARITHROMYCIN SUSP
MC
E.E.S.
MC/DEL
CLARITHROMYCIN TABS
MC
ERYPED 200 SUSR
MC
ERYPED 400 SUSR
MC
ERY-TAB TBEC
MC/DEL
ZITHROMAX TABS
MC
ERYTHROCIN STEARATE TABS
MC/DEL
ZITHROMAX 1GM PAK
ERYTHROMYCIN
MC/DEL
ZITHROMAX TRI-PAK
MC/DEL
ZITHROMAX SUSP
ZMAX
MC/DEL
MC
MC
MC/DEL
TETRACYCLINES
MC/DEL
DOXYCYCLINE MONOHYDRATE 100mg & 50mg
CAPS
MC
Use PA Form# 20420
DECLOMYCIN TABS
MINOCYCLINE HCL CAPS
MC/DEL
DORYX CPEP
MC/DEL
TETRACYCLINE HCL CAPS
MC/DEL
DOXYCYCLINE HYCLATE
MC/DEL
DOXYCYCLINE MONOHYDRATE 150mg & 75mg CAPS
MC/DEL
DYNACIN CAPS
VIBRAMYCIN SYRP
PERIOSTAT
MC/DEL
SOLODYN ER
CIPROFLOXACIN
MC
AVELOX SOLN
MC/DEL
LEVOFLOXACIN
MC
AVELOX TABS
MC/DEL
OFLOXACIN
MC
AVELOX ABC PACK TABS
MC
MC
CIPRO
FACTIVE
MC
LEVAQUIN TABS SOLN/INJ
MC
MC
LEVAQUIN TABS
NOROXIN TABS
MC
PROQUIN XR
MC
MC/DEL
GENTAMICIN
KITABIS PAK
NEOMYCIN SULFATE TABS
MC
MC/DEL
MC
MC/DEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
ORACEA
MC/DEL
MC/DEL
MC
DDI: Preferred erythromycin will now be non-preferred and require prior authorization if it is currently being used in combination with either Carbamazepine, Enablex 15mg or Vesicare
10mg. Any non preferred formulation of erythromycin will require prior authorization and the member's drug profile will also be monitored for concurrent use with either Carbamazepine,
Enablex 15mg or Vesicare 10mg.
DDI: Preferred clarithromycin formulations (clarithromycin tablets) will now be non-preferred and require prior authorization if they are currently being used in combination with either
Carbamazepine, Onglyza 5mg, Enablex 15mg or Vesicare 10mg. Any non preferred formulation of clarithromycin will require prior authorization and the member's drug profile will also
be monitored for concurrent use with either Carbamazepine, Onglyza 5mg, Enablex 15mg or Vesicare 10mg.
Use PA Form# 20420
MC
AMINO GLYCOSIDES
DIFICID
PCE TBEC
MC/DEL
MC/DEL
FLUOROQUINOLONES
1. 7- Day supply per month Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
without PA.
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
1. Dosing limits apply, see
Dosage Consolidation List.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DDI: Preferred ofloxacin will now be non-preferred and require prior authorization if they are currently being used in combination with amiodarone.
DDI: Preferred levofloxacin will now be non-preferred and require prior authorization if they are currently being used in combination with amiodarone.
DDI: Preferred Avelox will now be non-preferred and require prior authorization if they are currently being used in combination with amiodarone.
DDI: All preferred fluoroquinolones will require clinical PA for patients over 60 that are currently on immunosuppressants or steroid therapy.
1
BETHKIS1
TOBI PODHALER1
TOBI NEBU2
TOBRAMYCIN SULFATE SOLN2
DDI: Factive is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with amiodarone.
Use PA Form# 20420
1. Clinial PA to verify
appropriate diag
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. See criteria section
TOBI Podhaler is limited to patients with significant impairment from using nebulized version of medication
Current users of Tobi Nebu and Tobramycin Soln will be allowed a grace period until 10/1/15 to transition to preferred Kitabis.
ANTI-MYCOBACTERIALS / ANTITUBERCULOSIS
ANTIMALARIAL AGENTS
ANTHELMINTICS
MC/DEL
ETHAMBUTOL HCL TABS
MC/DEL
MYAMBUTOL TABS
MC/DEL
MYCOBUTIN CAPS
MC/DEL
RIFAMPIN
MC/DEL
CHLOROQUINE PHOSPHATE TABS
MC/DEL
DARAPRIM TABS
MC/DEL
MEFLOQUINE HCL TABS
MC/DEL
PLAQUENIL TABS
MC/DEL
QUININE SULFATE
MC/DEL
ALBENZA TABS
MC
MC/DEL
ANTIBIOTICS - MISC.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DDI: Preferred rifampin will be non-preferred and require prior authorization if it is currently being used in combination with either Pradaxa or Latuda.
MC
MC/DEL
MC
MC/DEL
ARALEN TABS
Use PA Form# 20420
HYDROXYCHLOROQUINE TABS
ISONARIF1
MALARONE TABS
1. Ingredients available as
preferred without PA.
Use PA Form# 20420
BILTRICIDE TABS
STROMECTOL TABS
MC
AZACTAM SOLR
MC
COLISTIMETHATE SODIUM SOLR
MC
COLY-MYCIN-M SOLR
MC
MC
COLISTIMETHATE SODIUM SOLR
CAYSTON3
FLAGYL CAPS
MC/DEL
1. 375mg caps and 750mg
tabs are non-preferred.
Please use available
preferred strengths(250mg
Page &2500mg
of 58tabs) to obtain
required dose without PA.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC
tabs are non-preferred.
Please use available
preferred strengths(250mg
& 500mg tabs) to obtain
required dose without PA.
FUROXONE TABS
MC/DEL
FLAGYL TABS
MC/DEL
FLAGYL ER TBCR
MC
METRONIDAZOLE1
PENTAMIDINE ISETHIONATE SOLR
MC/DEL
KETEK
MC
PRIMSOL SOLN
MC/DEL
METRONIDAZOLE 375MG CAPS
MC/DEL
TRIMETHOPRIM TABS
MC/DEL
MC/DEL
VANCOMYCIN 5GM INJ.
MC
METRONIDAZOLE 750MG TABS
NEBUPENT SOLR
MC
TINDAMAX
MC/DEL
MC/DEL
MC
VANCOMYCIN 10GM INJ.
XIFAXAN
MC
INVANZ SOLR
MC
MERREM SOLR
1. For macrolide resistant infections when quinolones inappropriate
DDI: Ketek is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either Enablex 15mg or Vesicare 10mg
or carbamazepine.
1
1
2. Please use multiple 5gm Cayston is only indicated to improve respiratory symptoms in CF patients with Pseudomonas aeruginosa. Dosing limits, as should be given TID X28 days (followed by 28 days OFF
which are preferred to obtain Cayston therapy). A bronshodilator should be used before administration of Cayston.
dose without PA.
2
3. Clinical PA is required to
establish CF diagnosis and
medical necessity. Prior trail
and failure of preferred Tobi
before approval will be
granted.
Use PA Form# 20420
CARBAPENEMS
LINCOSAMIDES / OXAZOLIDINONES /
LEPROSTATICS
MC/DEL
PRIMAXIN
MC/DEL
CLEOCIN SOLN
MC/DEL
CLEOCIN CAPS
MC/DEL
CLEOCIN SUSR
MC/DEL
MC/DEL
CLINDAMYCIN HCL 150CAPS
CLINDAMYCIN HCL 300CAPS
SIVEXTRO
MC
ANTI INFECTIVE COMBO'S - MISC.
DAPSONE TABS
MC/DEL
ERYTHROMYCIN/SULF SUSR
MC/DEL
SEPTRA/DS TABS
MC/DEL
SULFAMETHOXAZOLE/TRIMETH
MC/DEL
TRIMETHOPRIM/SULFAMETHOXA
ANTIPROTOZOALS
MC
1
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Use multiple 150's for
Clindamycin instead of
300's.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. For Zyvox or Vibativ, please see the criteria listed in the Antibacterial Antibiotics PA form.
MC/DEL
VIBATIV
MC/DEL
ZYVOX SUSR
Use PA Form# 30820 for
Zyvox & Vibativ
MC/DEL
ZYVOX TABS
Use PA Form# 20420 for all
others
MC
BACTRIM DS TABS
Use PA Form# 20420
MC
ALINIA1
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Alina is preferred for
children less than 12 years
of age.
Use PA Form# 20420
ANTIFUNGALS - ASSORTED
MC
ANCOBON CAPS
ANTI - FUNGALS
MC/DEL
6
LAMISIL TABS4
ITRACONAZOLE
MC/DEL
FLUCONAZOLE
MC/DEL
6
MC/DEL
KETOCONAZOLE TABS7
NYSTATIN
MC/DEL
MC/DEL
8
8
CRESEMBA9
TERBINAFINE TABS4
VORICONAZOLE TABS
MC
8
GRISEOFULVIN SUSP
MC
8
GRISEOFULVIN ULTRAMICROSI TABS
MC
8
GRIS-PEG TABS
MC/DEL
8
SPORANOX SOLN2
MC/DEL
8
SPORANOX PULSEPAK CAPS3
MC/DEL
8
MC/DEL
8
SPORANOX CAPS3
DIFLUCAN
MC/DEL
8
ERAXIS INJ6
MC
8
GRIFULVIN SUSP
MC/DEL
MC/DEL
MC/DEL
1
GRIFULVIN V TABS
1. QL--1/every 7-day period Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
(150mg only).
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. The other criteria are listed on the Antifungal PA form including the required proof of a non-cosmetic fungal infection.
2. Sporanox QL
300cc/month with PA. See
quantity limit table.
3. Sporanox QL 30/month
with PA. See quantity limit
table. Non-preferred
products must be used in
specified step order.
DDI: Any Griseofulvin will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently
Continue to use Anti-Fungal non preferred PPI.
PA form for non-preferred
products.
DDI: Sporanox is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for current use with Enablex 15mg, Vesicare 10mg, Prandin,
Prevacid, pantoprazole, Prilosec, or any currently non preferred PPI, due to a significant drug-drug interaction.
4. Quantity limit of one
tablet daily. Please see
dosage consolidation list.
Page 3 of 58
DDI: Vfend is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with Warfarin.
MC/DEL
MC/DEL
8
8
ONMEL
DDI: Fluconazole (except 150mg strength) will now be non-preferred and require prior authorization if it is currently being used with glimepiride (Amaryl), Enablex 15mg, or Vesicare
5. Approved if immuno
10mg. Diflucan is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either glimepiride (Amaryl), Enablex
suppressed/ HIV or if the
15mg, or Vesicare 10mg.
member has failed a 7 day
trial of a preferred antifungal
therapy.
DDI: Fluconazole will require prior authorization if being used in combination with Plavix or Warfarin.
NOXAFIL5
6. Eraxis will be approved if
submitting with
documentation that it was
initiated during a
hospitalization and this
request is to finish the
hospital course.
MC/DEL
8
VFEND TABS
7. Quantity limits allowing 30
day supply without PA. PA
will be required if using > 30
days.
DDI: Ketoconazole will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following medications: Prevacid,
Pantoprazole, Plavix, Onglyza, Enablex 15mg, Vesicare 10mg, Latuda, Cometriq, Tafinlar or Omeprazole.
8. For children < 18,
quantity limits allows 8
weeks supply without PA.
PA will be required if using >
than 8 weeks. If 18 and
older PA will be required for
any quantity. Not approving
for Onychomycosis
indication.
9. For patients ≥ 18years of
age
Use PA Form# 10120
ANTIRETROVIRALS
MC/DEL
APTIVUS
MC
MC/DEL
ATRIPLA1
CRIXIVAN CAPS
MC/DEL
EDURANT
MC
ANTI - VIRALS
MC/DEL
8
COMBIVIR TABS
MC
8
COMPLERA
MC/DEL
8
DIDANOSINE
8
8
EVOTAZ
EMTRIVA
MC/DEL
MC/DEL
MC/DEL
EPIVIR / HBV
MC/DEL
8
INTELENCE3
MC/DEL
EPZICOM
MC/DEL
8
MC
MC/DEL
GENVOYA9
INVIRASE CAPS
MC/DEL
MC
ISENTRESS3,4
PREZCOBIX
RETROVIR
KALETRA
FUZEON3
MC/DEL
8
8
8
MC/DEL
LEXIVA
MC
8
MC
NORVIR
MC
8
STRIBILD
TIVICAY5,6
MC
PREZISTA2
RESCRIPTOR TABS
MC
8
TRIUMEQ5,7
MC
MC
8
8
TYBOST8
MC
MC/DEL
8
9
VITEKTA
VIRAMUNE XR
MC
MC/DEL
MC
MC
REYATAZ1
STAVUDINE
MC
SUSTIVA
MC/DEL
TRIZIVIR TABS
MC
TRUVADA
MC
VIDEX EC
MC/DEL
VIRACEPT TABS
MC/DEL
VIRAMUNE TABS
MC
VIREAD TABS
MC/DEL
ZIAGEN TABS
MC/DEL
ZIDOVUDINE
SELZENTRY3
ZERIT
Use PA Form# 10620 for
Fuzeon
Please refer to the criteria listed on the Fuzeon PA form.
Use PA Form# 20420 for all
others
1. Quantity limit of one per DDI: Reyataz will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently non
day
preferred PPI .
2. Only preferred if Norvir
script is in member's profile DDI: Preferred Norvir will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
within the past 30 days of
filling Prezista
3. Prescribers with >= 10
DDI: Preferred Crixivan caps will now be non-preferred and require prior authorization if it is currently being used in combination with either Enablex 15mg or Vesicare 10mg.
ART scripts per quarter and
75% ART PDL compliance
will be exempt from PA for
EDURANT® treated subjects with HIV-1 RNA greater than 100,000 copies/mL at the start of therapy experienced virologic failure (HIV-1 RNA greater than or equal to 50 copies/mL)
these products.
compared to EDURANT® treated subjects with HIV-1 RNA less than or equal to 100,000 copies/mL. Regardless of HIV-1 RNA at the start of therapy, more EDURANT® treated
subjects with CD4+ cell count less than 200 cells/mm3 experienced virologic failure compared to EDURANT® treated subjects with CD4+ cell count greater than or equal to 200
cells/mm3.
4.Isentress Chewable will
only be approved if between
the age of 2-12 years old
Stribild needs specific indication(only indicated for HIV-1 infection in adults who are antiretroviral treatment-naïve), as there is a boxed warning that this is not indicated for Hep B and
5. Clinical PA is required to
establish diagnosis,
verification of age for
appropriate indication and
medical necessity.
6. Dosing limits apply,
Page please
4 of 58
see dosing
consolidation list.
has not been studied in those co-infected with HIV-1 and HBV. Should not be co-administered with other antiretroviral medications used for HIV1 infections, as this is a complete
regimen
DDI: Nevirapine, oxcarbazepine, phenytion, phenobarbital, carbamazepine, and St. John;s wort will be non-preferred and require prior authorization if it is currently being used in
combination with Tivicay.
DDI:Aatazanavir or darunavir and the following drugs are contraindicated (due to potential for serious and/or life-threatening events or loss of therapeutic effect): alfuzosin,
dronedarone, rifampin, irinotecan, dihydroergotamine, ergotamine, methylergonovine, cisapride, St. John’s wort, lovastatin, simvastatin, pimozide, nevirapine, sildenafil (when given as
Revatio® for treatment of PAH), indinavir, triazolam, or PO midazolam will be non-preferred and require prior authorization if it is currently being used in combination with Tybost.
6. Dosing limits apply,
DDI:Aatazanavir or darunavir and the following drugs are contraindicated (due to potential for serious and/or life-threatening events or loss of therapeutic effect): alfuzosin,
please see dosing
dronedarone, rifampin, irinotecan, dihydroergotamine, ergotamine, methylergonovine, cisapride, St. John’s wort, lovastatin, simvastatin, pimozide, nevirapine, sildenafil (when given as
consolidation list.
Revatio® for treatment of PAH), indinavir, triazolam, or PO midazolam will be non-preferred and require prior authorization if it is currently being used in combination with Tybost.
7. Request will require use
of the individual components
Tivicay and Epzicom.
8. Diagnosis and verify prior
trials and failures or
intolerance of preferred
treatments is required
9. Preferred for the
treatment of HIV-1 infection
in adults and pediatric
patients ≥ 12 years of age
CYTO-MEGALOVIRUS AGENTS
HERPES AGENTS
INFLUENZA AGENTS
Evotaz is only available if unable to tolerate or have failed Reyataz and Norvir
Prezcobix is only available if unable to tolerate or have failed Prezista and Norvir
Genvoya is available to those for whom there is a clinical need for the improved renal safety profile provided by tenofovir alafenamide that cannot be met with other more cost-effective
combination regimens and also to document that the patient is either treatment naïve or virologically-suppressed (HIV-1 RNA < 50 copies/ml) on a stable antiretroviral regimen for at
least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of Genvoya.
MC
FOSCARNET SODIUM
MC/DEL
FOSCAVIR
MC
VALCYTE TABS
MC/DEL
GANCICLOVIR
MC/DEL
ACYCLOVIR
MC/DEL
8
MC/DEL
VALACYCLOVIR HCL
MC
MC/DEL
8
8
MC/DEL
8
VALTREX TABS1
MC/DEL
9
FAMVIR TABS1
Use PA Form# 20420
FLUMADINE TABS
1. Tamiflu 10 caps or 60cc's Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
per month. Will be audited exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
for presence of positive
another drug and the preferred drug(s) exists.
influenza tests in patient or
family member.
MC/DEL
MC
AMANTADINE
RELENZA DISKHALER AEPB
MC/DEL
RIMANTADINE HCL TABS
MC/DEL
TAMIFLU1
MC
MC
FAMCICLOVIR1
SITAVIG
1
ZOVIRAX
FLUMIST
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Must fail Acyclovir and
Valacyclovir before nonpreferred products in step
order.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Use PA Form# 10610 for
Flumist requests
Use PA Form# 20420 for all
others
IMMUNE SERUMS
IMMUNE SERUMS
MC
HYPERRHO INJ
HEPATITIS C AGENTS
MC
HARVONI2
MC
MC/DEL
MC/DEL
MC/DEL
OLYSIO2
PEGASYS KIT1
PEGASYS SOLN
MC
PEG-INTRON KIT1
RIBAVIRIN
MC
SOVALDI2
MC
MC
TECHNIVIE2
MC/DEL
HEPATITIS AGENTS
MC/DEL
COPEGUS TABS
MC/DEL
MC/DEL
DAKLINZA
REBETOL CAPS
MC
RIBAPAK
1. Dosing limits apply,
please see dosage
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
2. Approvals will require
clinical PA. Please see the
DDI: Olysio will require a prior authorization if it is currently being used in combination with drugs known to be significant CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin,
Hepatitis PA form for criteria
indinavir, nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
VIEKIRA PAK2
RIBASPHERE
Use PA Form# 10700
Page 5 of 58
HEPATITIS AGENTS - MISC.
HEPATITIS B ONLY
MC
HEPSERA TABS
MC
ACTIMMUNE
Use PA Form# 20420
Approved for chronic granulomatous disease, osteopetrosis and idiopathic pulmonary fibrosis.
MC
BARACLUDE
Use PA Form# 20420
MC
TYZEKA
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Baraclude is indicated for treatment of chronic Hep B virus (HBV) in adults with: evidence of active viral replication AND either evidence of persistent elevation in serum
aminotransferases (ALT or AST) or histologically active disease, Patient is 16 years of age or older. Boxed warning: Use not recommended for those co-infected with HIV and HBV who
are not also receiving highly active antiretroviral therapy (HAART).
RSV PROPHYLAXIS
RSV PROPHYLAXIS
Please see the criteria listed on the Synagis PA form.
Use PA Form# 30120
1. MaineCare will approve
Synagis PA's for start date
of November 23rd for infants
who meet the guidelines.
PA will be approved for max
of 5 doses. Maximum 1
dose/30 days.
SYNAGIS1
MC
MS TREATMENTS
MULTIPLE SCLEROSIS - INTERFERONS
MC
MC/DEL
AVONEX KIT1
BETASERON SOLR
1
PLEGRIDY
MC
1
MC/DEL
EXTAVIA
MC
REBIF SOLN1
MC
COPAXONE 20MG2
MC
6
GILENYA2,3
MC
8
TYSABRI1
AMPYRA
MC
8
COPAXONE 40MG
MC/DEL
MC
8
8
GLATOPA
TECFIDERA
1.Clinical PA is required to
establish diagnosis and
medical necessity.
Non-Preferred drugs must be tried in step-order and failed due to lack of efficacy or intolerable side effects before lower ranked non-preferred drugs will be approved , unless an
acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
interaction between another drug and the preferred drug(s) exists.
Use PA Form# 20430
MULTIPLE SCLEROSIS - NONINTERFERONS
MC/DEL
MC
AUBAGIO
1. Providers must be
enrolled in the TOUCH
Prescribing program, a
restricted distribution
program. Clinical PA is
required to establish
diagnosis and medical
necessity.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Aubagio is preferred and is for adults with relapsing forms of MS. No concurrent use of leflunomide . Within 6 months of initiation of Aubagio, lab testing to look at (transaminase,
bilirubin, CBC, TB) as boxed warning exists regarding hepatoxicity.
2. Clinical PA is required to
establish diagnosis and
medical necessity.
3. Dosing limits apply,
please see dosage
consolidation list.
Use PA Form# 20430
ASSORTED NEUROLOGICS
NEUROLOGICS - MISC.
MC/DEL
ORAP TABS
MC
BOTOX2
MC
PROSTIGMIN TABS
MC
MC
PYRIDOSTIGMINE
MC
DYSPORT1
MESTINON
MC
MYOBLOC1
1. Approval will be limited to Failed/did not tolerate therapeutic trials fo muscle relaxants, unless contraindicated, including but not limited to baclofen, cyclobenzaprine, orphenadrine, Skelaxin, and tizanidine.
Cervical dystonia.
Migraine: Consideration for Botox approvals will only be made after failures of required trials of the following preferred medications: tricyclic or venlafaxine,beta blocker,valproic acid
2. Please see botulinum PA ,topiramate
form for additional criteria
Use PA Form# 10210
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
STEROIDS
GLUCOCORTICOIDS/
MINERALOCORTICOIDS
MC
CELESTONE SUSP
MC/DEL
MC
BUDESONIDE EC
MC/DEL
CORTEF 5
MC/DEL
CORTISONE ACETATE TABS
MC/DEL
FLORINEF TABS
MC/DEL
DELTASONE TABS
MC/DEL
MEDROL TABS
MC/DEL
DEPO-MEDROL SUSP
MC
Use PA Form# 20420
CORTEF 10 and 20 TABS
MEDROL DOSEPAK TABS
Page 6 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC/DEL
DEXAMETHASONE
DEXPAK
MC
MC
MILLIPRED
ORAPRED SOLN
MC/DEL
ENTOCORT EC CP24
MC
PEDIAPRED LIQD
MC/DEL
FLUDROCORTISONE ACETATE TABS
MC
PREDNISONE INTENSOL CONC
MC/DEL
HYDROCORTISONE
MC
STERAPRED TABS
MC
MC
KENALOG
DDI: All preferred steroids will require clinical PA for patients over 60 that are currently on fluoroquinolone therapy.
MC/DEL
METHYLPREDNISOLONE TABS
MC/DEL
PREDNISOLONE
MC/DEL
PREDNISONE
MC/DEL
SOLU-CORTEF SOLR
MC/DEL
SOLU-MEDROL SOLR
MC/DEL
ANDRODERM PT24
MC/DEL
MC/DEL
ANDROGEL 1%
DANAZOL CAPS
MC/DEL
DEPO-TESTOSTERONE OIL
MC/DEL
METHITEST TABS
HORMONE REPLACEMENT THERAPIES
ANDROGENS / ANABOLICS
MC
MC
ANADROL-50
ANDRO LA 200 OIL
MC/DEL
MC/DEL
ANDROGEL 1.62%
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Additionally, laboratory evidence of a testosterone deficiency must be supplied. One of each dosage form should be tried (tablet, injection, and topical)
1. Both preferred drugs
must be tried.
Approved for failures on multiple oral estrogen agents after 90 day trials or if unable to swallow any oral medication.
ANDROGEL PUMP
MC
ANDROID CAPS
MC
AXIRON
MC
DELATESTRYL OIL
MC
FORTESTA
MC
HALOTESTIN TABS
MC
NATESTO
MC/DEL
MC
OXANDROLONE
TESTIM
MC/DEL
TESTOSTERONE CYP
MC
TESTRED CAPS
MC/DEL
ESTROGENS - PATCHES / TOPICAL
Use PA Form# 20420
VOGELXO
MC/DEL
VIVELLE-DOT PTTW1
MC/DEL
5
ESTRADIOL PTWK
MC/DEL
CLIMARA PTWK
MC/DEL
8
ALORA PTTW2
MC/DEL
8
DIVIGEL2
MC/DEL
8
ELESTRIN2
MC
8
EVAMIST2
2. Step order drugs must be
used in specified step order.
Use PA Form# 20420
ESTROGENS - TABS
ESTROGEN COMBO'S
PROGESTINS
MC/DEL
CENESTIN TABS
MC/DEL
MC/DEL
ESTRADIOL
MC/DEL
ENJUVIA
ESTRACE TABS
MC/DEL
ESTROPIPATE TABS
MC
ESTRATAB TABS
MC/DEL
MENEST TABS
MC
ORTHO-EST TABS
MC/DEL
PREMARIN TABS
MC/DEL
PREMPHASE TABS
MC/DEL
ACTIVELLA TABS1
MC/DEL
PREMPRO TABS
MC/DEL
COMBIPATCH PTTW1
MC/DEL
FEMHRT 1/5 TABS1
MC/DEL
ORTHO-PREFEST TABS1
MC/DEL
SYNTEST H.S. TABS1
MC/DEL
AYGESTIN TABS
MC
MAKENA3
Use PA Form# 20420
MC/DEL
MEDROXYPROGESTERONE ACETA 2
MC
CYCRIN TABS
MC/DEL
NORETHINDRONE ACETATE TABS2
17-ALPH HYDROXYPROGESTERONE3
MC
PROGESTERONE POWD
MC/DEL
PROMETRIUM 100MG CAPS1
MC/DEL
PROMETRIUM 200MG1
PROVERA TABS
MC
Must fail preferred products Preferred drugs must be tried for at least 90 days and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
before non-preferred
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
products.
another drug and the preferred drug(s) exists.
MC/DEL
1. Must fail Premphase and Preferred drugs must be tried for at least 90 days and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
Prempro products before
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
non preferred products.
another drug and the preferred drug(s) exists.
Use PA Form# 20420
1. PA approvals will require Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
two 100 mg caps instead of on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
one 200mg.
preferred drug(s) exists.
2. Must fail
Medroxyprogesterone and
Norethidrone products
before non-preferred
products.
3. Clinical PA required for
indication to reduce the risk
of preterm birth in women
with a singleton pregnancy
who have a history of
singleton spontaneous
preterm birth.
Page 7 of 58
Use PA Form# 20420
CONTRACEPTIVES
CONTRACEPTIVES - PROGESTIN ONLY
MC/DEL
NOR-QD TABS
MC/DEL
7
CAMILA TABS
MC/DEL
NORETHINDRONE ACETATE 0.35 TABS
MC/DEL
7
ERRIN
MC/DEL
7
JOLIVETTE
MC/DEL
MC
7
NORA-BE TABS
8
ORTHO MICRONOR TABS
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
If member experienced adverse reactions, consider using Oral Contraceptives from other groups.
DDI: Preferred Oral Contraceptives will now be non-preferred and require prior authorization if it is currently being used in combination with Tracleer.
Use PA Form# 20420
CONTRACEPTIVES - INJECTABLE
MC/DEL
CONTRACEPTIVE - EMERGENCY
MC/DEL
1
MC/DEL
CONTRACEPTIVES - PATCHES/ VAGINAL
PRODUCTS
MEDROXYPROGESTERONE ACETATE 150mg IM
MC/DEL
DEPO-PROVERA 150 mg SUSP
Use PA Form# 20420
MC/DEL
PLAN B
2
PLAN B ONE STEP1
ELLA
1. Allowed 2 tablets per 30
days without PA
MC
2
LEVONORGESTREL
MC/DEL
2
NEXT CHOICE1
MC/DEL
XULANE
MC
NUVARING RING1
The preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists.
Use PA Form# 20420
2
Use PA Form# 20420
1. Quantity limit allowing 1
every 28 days with out PA.
Approved if adequate clinical reason given why patient unable to comply with other preferred agents including long acting injectable.
2. Dose limits apply
allowing 3 patches per 28
days supply.
CONTRACEPTIVES - MONOPHASIC
COMBINATION O/C'S
MC/DEL
MC/DEL
APRI TABS
AVIANE TABS
MC/DEL
BEYAZ
MC/DEL
BREVICON-28 TABS
MC/DEL
MC/DEL
BALZIVA
CRYSELLE-28 TABS
MC/DEL
LESSINA-28 TABS
MC/DEL
LEVORA
MC
MC/DEL
MC
MC
LOESTRIN TABS
DESOGESTREL/ ETHINYL ESTRADIOL
LOW-OGESTREL TABS
MC/DEL
LOESTRIN FE TABS
MC/DEL
LOESTRIN FE 1/20 TABS
MODICON TABS
MC/DEL
LOESTRIN 1.5/30-21 TABS
MC/DEL
MONONESSA
MC/DEL
LOESTRIN 1/20-21 TABS
MC/DEL
MC
NECON 1/50
MC
LO/OVRAL 21 TABS
ORTHO-CEPT-28 TABS
MC/DEL
LO/OVRAL 28 TABS
ORTHO-CYCLEN-28 TABS
MC/DEL
MICROGESTIN FE TABS
ORTHO-NOVUM 1/35-28 TABS
MC/DEL
NORDETTE-28 TABS
MC/DEL
OVCON-50 28 TABS
MC/DEL
NORINYL
MC/DEL
PREVIFEM
MC/DEL
NORTREL
MC/DEL
RECLIPSEN
MC/DEL
MC/DEL
MC/DEL
MC/DEL
OCELLA
OGESTREL TABS
MC/DEL
SOLIA
SPRINTEC 28 TABS
MC/DEL
YASMIN 28 TABS
MC/DEL
OVRAL
MC/DEL
MC/DEL
YAZ
MC/DEL
PORTIA-28 TABS
ZENCHENT
MC/DEL
SAFYRAL
MC/DEL
ZOVIA
MC/DEL
NECON 10/11-28 TABS
MC
MC
CONTRACEPTIVES - BI-PHASIC
COMBINATIONS
DESOGEN TABS
MC
ORTHO-NOVUM 10/11-28 TABS
MC
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1- MC/DEL
35
MC/DEL
SEASONIQUE
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
Use PA Form# 20420
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
If member experienced
adverse reactions, consider preferred drug(s) exists.
using Oral Contraceptives
from other groups.
If member experienced adverse reactions, consider using Oral Contraceptives from other groups.
DDI: Preferred Oral Contraceptives will now be non-preferred and require prior authorization if it is currently being used in combination with Tracleer.
OVCON-35/28 TABS
KARIVA TABS
MC/DEL
LOSEASONIQUE
MC/DEL
MIRCETTE TABS
If member experienced
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
adverse reactions, consider on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
using Oral Contraceptives preferred drug(s) exists.
from other groups.
If member experienced adverse reactions, consider using Oral Contraceptives from other groups.
DDI: Preferred Oral Contraceptives will now be non-preferred and require prior authorization if it is currently being used in combination with Tracleer.
Use PA Form# 20420
CONTRACEPTIVES - TRI-PHASIC
COMBINATIONS
MC/DEL
ENPRESSE
MC/DEL
CYCLESSA TABS
MC/DEL
NECON 7/7/7
MC/DEL
ESTROSTEP FE TABS
ORTHO-NOVUM 7/7/7-28 TABS
MC/DEL
NORTREL 7/7/7
MC
If member experienced
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
adverse reactions, consider on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
using Oral Contraceptives preferred drug(s) exists.
Page from
8 ofother
58groups.
adverse reactions, consider on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
using Oral Contraceptives preferred drug(s) exists.
from other groups.
MC/DEL
TRI-NORINYL 28 TABS
MC
ORTHO TRI-CYCLEN TABS
MC/DEL
TRI-PREVIFEM
MC
ORTHO TRI-CYCLEN LO TABS
MC/DEL
TRIPHASIL 28 TABS
If member experienced adverse reactions, consider using Oral Contraceptives from other groups.
MC/DEL
TRI-SPRINTEC
DDI: Preferred Oral Contraceptives will now be non-preferred and require prior authorization if it is currently being used in combination with Tracleer.
MC
MC/DEL
TRINESSA
TRIVORA-28 TABS
Use PA Form# 20420
CONTRACEPTIVES - MULTI-PHASIC
COMBINATIONS
MC
NATAZIA
Use PA Form# 20420
DIABETES THERAPIES
DIABETIC - INSULIN
MC
HUMALOG INJ 100/ML
MC/DEL
APIDRA
MC
HUMALOG MIX 75/25
AFREZZA1
MC
MC
HUMALOG 50/50 VIAL
HUMULIN N INJ U-100
MC/DEL
MC
MC
HUMULIN INJ 70/30
MC
MC
MC
MC/DEL
HUMULIN R U-100
MC/DEL
NOVOLIN
LANTUS SOLN
LEVEMIR
MC/DEL
NOVOLOG
MC/DEL
MC
NOVOLOG MIX
MC/DEL
DIABETIC - PENFILLS
DIABETIC - DPP- 4 ENZYME INHIBITOR
Use PA Form# 20420
HUMALOG MIX PEN 50/50
HUMULIN INJ 50/50
HUMULIN R INJ U-500
1. Not to be as a
monotherapy. Obtain lab
values of pulmonary function
and recent smoking history
RELION
MC/DEL
LANTUS SOLOSTAR1
MC
APIDRA OPTICLIK PEN
MC/DEL
LEVEMIR FLEXPEN1
MC
HUMALOG KWIK INJ 100/ML
MC/DEL
NOVOLIN PENFILL1
MC
HUMALOG MIX INJ 75/25 KWP
MC/DEL
NOVOLIN 70/301
MC
HUMALOG MIX INJ 50/50 KWP
MC/DEL
NOVOLOG MIX PENFILL1
MC/DEL
TOUJEO
MC/DEL
NOVOLOG PENFILL SOLN1
MC/DEL
TRESIBA
MC/DEL
NOVOLOG MIX FLEXPEN
MC/DEL
NOVOLOG FLEXPEN
MC/DEL
JANUVIA
MC/DEL
TRADJENTA2
1,2
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Clinical PA will be
required to establish
significant visual or
neurological impairment.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
1
1
Use PA Form# 20420
MC/DEL
ONGLYZA
2
1. Preferred if therapeutic
doses of metformin are seen
in members drug profile for
at least 60 days within the
past 18 months or if
phosphate binder is
currently seen in the
members drug profile.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
DDI: Onglyza 5mg will require a prior authorization if it is currently being used in combination with drugs known to be significant CYP3A4 inhibitors (ketoconazole, itraconazole,
clarithromycin, indinavir, nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
2. Dosing limits apply.
Please refer to Dose
consolidation list.
Use PA Form# 20420
DIABETIC - DPP- 4 ENZYME INHIBITORCOMBO
MC/DEL
JANUMET1,2
MC/DEL
JANUMET XR1,2
MC
MC/DEL
JENTADUETO1
MC/DEL
MC/DEL
KAZANO
KOMBIGLYZE XR
OSENI
1. Preferred if therapeutic
doses of metformin are seen
in members drug profile for
at least 60 days within the
past 18 months or if
phosphate binder is
currently seen in the
members drug profile.
2. Dosing limits apply.
Please refer to Dose
consolidation list.
Use PA Form# 20420
DPP- 4 ENZYME INHIBITOR/ HMGCOS REDUCTASE INHIBITOR
MC/DEL
JUVISYNC1,2
Use PA Form# 20420
Page 9 of 58
DDI: Juvisync will require a prior authorization if used in concurrent use with drugs known to be significant CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, indinavir,
nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
DDI: Juvisync will require a prior authorization if used in concurrent use with drugs known to be significant CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, indinavir,
nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
DPP- 4 ENZYME INHIBITOR/ HMGCOS REDUCTASE INHIBITOR
1. Please refer to criteria
section of PDL
Juvisync will remain preferred until product is eventually discontinued later in 2014.
2. Dosing limits apply please
refer to Dose Consolidation
List
DIABETIC - LANCET-LANCET DEVICE
DIABETIC - SYRINGES-NEEDLES
MC
ONE TOUCH LANCETS
MC
DELICA LANCETS
MC
UNILET LANCETS
MC
UNISTIK LANCING DEVICE
MC
AUTOLOT LANCING DEVICE
MC/DEL
BD MICRO-FINE
MC
BD ULTRA-FINE
MC
BD ULTRA-FINE PEN NEEDLES
MC
UNIFINE PEN NEEDLES
DIABETIC - OTHER
Use PA Form# 20420
Use PA Form# 20420
MC/DEL
MC
CYCLOSET
SYMLIN
Use PA Form# 30150 for
Symlin
Please see the criteria listed in the Symlin PA form.
Use PA Form #20420 for all
others
SGLT 2 INHIBITORS
MC/DEL
FARXIGA2
MC/DEL
MC/DEL
INVOKANA1
JARDIANCE
1.Dosing limits apply please
refer to Dose Consolidation
List
Invokana will be considered for patients who are unable to tolerate any preferred medicaitons from other diabetic classes.
2. Preferred if therapeutic
doses of metformin are seen
in members drug profile for
at least 60 days within the
past 18 months
Use PA Form# 20420
SGLT 2 INHIBITOR COMBINATIONS
MC/DEL
MC/DEL
GLYXAMBI
MC/DEL
INVOKAMET
SYNJARDY
MC/DEL
XIGDOU XR1
1. Diagnosis required
Preferred drugs must be tried for at least 3 months at full therapeutic doses and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential
drug interaction between another drug and the preferred drug(s) exists.
Glyxambi /Xigduo XR- Verify prior trials and failures or intolerance of preferred treatments from other diabetic categories
Use PA Form# 20420
DIABETIC MONITOR
DIABETIC TEST STRIPS
MC
FREESTYLE INSULINX
FREESTYLE LITE SYSTEM KIT
MC
ACCUCHECK
MC
MC
ASCENSIA
MC
FREESTYLE FREEDOM LITE KIT
MC
ASSURE
MC
ONE TOUCH ULTRA 2 KIT
MC
MC
ONE TOUCH ULTRA MINI KIT
MC
CONTOUR BREEZE Z
EXACTECH
MC
ONE TOUCH ULTRA SMART KIT
MC
PRODIGY
MC
PRECISION XTRA METER
MC
FREESTYLE1
MC
ACCUCHECK
MC
FREESTYLE LITE1
MC
ASCENSIA
MC
FREESTYLE INSULINX1
MC
ASSURE
MC
ONE TOUCH DELICA1
MC
EXACTECH
MC
ONE TOUCH ULTRA1
MC
PRODIGY
MC
PRECISION XTRA1
MC
CONTOUR BREEZE Z
Use PA Form# 20420
Effective October 25th 2007, approvals for all non preferred meters/ test strips will require medical necessity documenting clinically significant features that are not available on any of
the preferred meters.
1. Only 50 ct & 100 ct
package size.
Effective October 25th 2007, approvals for all non preferred meters/ test strips will require medical necessity documenting clinically significant features that are not available on any of
the preferred meters.
Use PA Form# 20420
Page 10 of 58
INCRETIN MIMETIC
MC
MC/DEL
BYDUREON
TANZEUM
MC
8
BYETTA1
MC/DEL
8
MC
MC/DEL
8
9
NESINA
TRULICITY2
VICTOZA1
1. If patient is not
responding to oral agents
Trulicity- Verify prior trials and failures or intolerance of preferred treatments from other diabetic categories and that is not being used as first-line treatment
(single or multiple) please
look to insulin therapy.
Dosing limits apply. Please
refer to Dose Consolidation
List.
2. Diagnosis required
Use PA Form# 10230
DIABETIC - ORAL SULFONYLUREAS
MC/DEL
CHLORPROPAMIDE TABS
MC/DEL
AMARYL TABS
MC/DEL
GLIMEPIRIDE
MC/DEL
DIABETA TABS
MC/DEL
GLIPIZIDE TABS
MC/DEL
GLIPIZIDE ER TABS
GLYBURIDE MICRONIZED TABS
MC/DEL
MC/DEL
GLUCOTROL XL TBCR
GLYBURIDE TABS1
TOLAZAMIDE TABS
MC/DEL
MICRONASE TABS
MC/DEL
MC/DEL
TOLBUTAMIDE TABS
MC/DEL
METFORMIN HCL TABS
MC
GLUCOPHAGE TABS
MC/DEL
METFORMIN ER
MC
GLUCOPHAGE XR TB24
MC
FORTAMET
MC/DEL
MC/DEL
DIABETIC -ORAL BIGUANIDES
DIABETIC - THIAZOL / BIGUANIDE
COMBO
DIABETIC - / THIAZOL
MC/DEL
PIOGLITAZONE HCL1
MC
GLUCOTROL TABS
GLYNASE TABS
MC/DEL
METFORMIN ER OSMOTIC
MC/DEL
MC/DEL
ACTOPLUS MET1
ACTOPLUS MET XR
MC/DEL
AVANDARYL1
MC/DEL
AVANDAMET TABS1
MC/DEL
ACTOS TABS3
MC/DEL
AVANDIA TABS2
Use PA Form# 20420
1. Pa required for members
≥65. Glyburide has a greater
risk of severe prolonged
hypoglycemia in older
adults.
Preferred drugs must be tried for at least 3 months at full therapeutic doses and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved,
unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential
drug interaction between another drug and the preferred drug(s) exists.
Use PA Form# 20420
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
1. Requires use of Actos,
Metformin, or other
preferred anti-diabetics.
DDI: Actos, Avandia, or any combination product with Actos or Avandia will now be non-preferred and require prior authorization if it is currently being used with gemfibrozil.
1. Pioglitazone HCL is nonpreferred as monotherapy.
Pioglitazone HCL is
preferred if therapeutic
doses of metformin,
sulfonylurea or insulin are
seen in members drug
profile for at least 60 days
within the past 18 months.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DDI: All sulfonylureas (except glyburide) will now be non-preferred and require prior authorization if it is currently being used with either ranitidine or cimetidine.
DDI: Glimepiride will now be non-preferred and require prior authorization if it is currently being used with either fluconazole (except 150mg strength) or fluvoxamine. Amaryl is nonpreferred but with any prior authorization requests, the member's drug profile will also be monitored for concurrent use with either fluconazole or fluvoxamine.
DDI: Actos, Avandia, or any combination product with Actos or Avandia will now be non-preferred and require prior authorization if it is currently being used with gemfibrozil.
2. Current users of Avandia
who have tried Actos will be
able to continue use of
Avandia.
3. Dosing limits apply please
refer to Dose Consolidation
List
Use PA Form# 20420
DIABETIC - ALPHAGLUCOSIDASE
MC/DEL
GLYSET TABS
MC
PRECOSE TABS
DIABETIC - SULFONYLUREA /
BIGUANIDE
MC/DEL
GLYBURIDE/METFORMIN
MC
GLUCOVANCE TABS1
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Use individual ingredients. Approved for patients failing to achieve good diabetic control with maximal doses of individual components.
Page 11 of 58
DIABETIC - SULFONYLUREA /
BIGUANIDE
1. Use individual ingredients. Approved for patients failing to achieve good diabetic control with maximal doses of individual components.
1
MC
METAGLIP TABS
MC/DEL
DUETACT2
MC/DEL
PRANDIN TABS
2. Use Actos with generic
glimepiride.
Use PA Form# 20420
DIABETIC - MEGLITINIDES
MC/DEL
STARLIX TABS
MC
Use PA Form# 20420
NATEGLINIDE
Preferred drugs from other diabetic sub-categories must be tried and failed due to lack of inadequate diabetic control or intolerable side effects before non-preferred drug will be
approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
significant potential drug interaction between another drug and the preferred drug(s) exists.
DDI: Prandin is non-preferred but with any prior authorization requests, the member's drug profile will also be monitored for current use with both Sporanox and gemfibrozil, due to a
significant drug-drug interaction.
GLUCOSE ELEVATING AGENTS
GLUCOSE ELEVATING AGENTS
MC/DEL
GLUCAGEN INJ. HYPOKIT
MC
GLUCAGON DIAGNOSTIC KIT
MC
GLUCAGEN DIAGNOSTIC KIT
MC
LEVOTHYROXINE SODIUM SOLR
Use PA Form# 20420
THYROID
THYROID HORMONES
ANTITHYROID THERAPIES
MC/DEL
ARMOUR THYROID TABS
MC/DEL
CYTOMEL TABS
MC/DEL
LEVOTHROID TABS
MC/DEL
LEVOTHYROXINE SODIUM TABS
MC/DEL
LEVOXYL TABS
MC/DEL
THYROID TABS
MC/DEL
THYROLAR
MC/DEL
UNITHROID TABS
MC/DEL
METHIMAZOLE TABS
MC/DEL
PROPYLTHIOURACIL TABS
MC/DEL
ALENDRONATE
MC/DEL
MIACALCIN SOLN2
MC/DEL
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
LIOTHYRONINE
MC
SYNTHROID TABS
MC/DEL
TAPAZOLE TABS
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
ACTONEL TABS
Use PA Form# 20420
1. Approval only requires
failure of Alendronate.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
OSTEOPOROSIS / BONE AGENTS
OSTEOPOROSIS
MC/DEL
MC
AREDIA SOLR
MC
BINOSTO
MC/DEL
BONIVA INJECTION KIT
MC/DEL
BONIVA TABS2,4
CALCITONIN NS
MC/DEL
MC/DEL
DUAVEE
DIDRONEL TABS
MC/DEL
EVISTA TABS1
FORTEO
MC
MC
MC/DEL
FORTICAL
MC/DEL
FOSAMAX TABS AND PLUS D3
MC
MC
STRENSIQ5
PROLIA
MC
XGEVA
MC/DEL
ZOMETA
2. Quantity limits apply,
please see dosage
consolidation list.
3. Please use Alendronate
and Vitamin D.
4. Please use other
preferred agents.
Binosto use preferred generic alendronate tablets
5. Obtain baseline
ophthalmology exams and
renal ultrasounds and then
periodically during treatment
CALCIMIMETIC AGENTS
CALCIMIMETIC AGENTS
SENSIPAR
MC
Use PA Form# 30115
Baseline PTH, Ca, and phosphorous levels are required and initial approvals will be limited to 3 months. Subsequent approvals will require additional levels being done to assess
changes. Will not approve if baseline Ca is less than 8.4.
GROWTH HORMONE
GROWTH HORMONE
MC/DEL
GENOTROPIN1
MC
MC/DEL
NORDITROPIN SOLN1
MC
8
8
HUMATROPE SOLR
INCRELEX
MC/DEL
8
NUTROPIN
MC
8
OMNITROPE
MC
8
SAIZEN SOLR
MC/DEL
8
TEV-TROPIN
MC/DEL
8
NUTROPIN AQ
Use PA Form# 10710
1.Clinical PA is required to
establish diagnosis and
medical necessity.
Page 12 of 58
See Growth Hormone PA form for criteria. Step-order will still apply unless clinical contraindication supplied.
SOMATOSTATIC AGENTS
MC/DEL
OCTREOTIDE INJ
MC/DEL
SANDOSTATIN
MC
SOMATULINE
Use PA Form# 10710
GROWTH HORMONE ANTAGONISTS
GH ANTAGONISTS
MC
SOMAVERT
Approved for acromegaly patients failing surgery/radiation/drug therapy including bromocriptine and sandostatin.
Use PA Form# 10710
VASOPRESSIN RECEPTOR ANTAGONIST
VASOPRESSIN RECEPTOR ANTAGONIST
MC/DEL
SAMSCA
Use PA Form# 20420
Samsca Drug Warning- Avoid use in patients with underlying liver disease, including cirrhosis, because the ability to recover from liver injury may be impaired. Limit duration of therapy
to 30 days to minimize the risk of liver injury.
URINARY INCONTINENCE
VASOPRESSINS
DESMOPRESSIN TABS
MC/DEL
5
DDAVP TABS
MC/DEL
6
DDAVP SOLN
MC/DEL
6
DESMOPRESSIN SPRAY1
MC
MC/DEL
8
DESMOPRESSIN ACETATE SOLN1
8
STIMATE SOLN1,2
1
1. Products must be used in Approved for central diabetes insipidus and for nocturnal enuresis. For nocturnal enuresis- must be over 6 years old, must fail an adequate trial of alarm training (higher success rate,
specified step order.
lower relapse rate) and must periodically attempt weaning (at 6 month intervals).
Nocturnal enuresis patients
will be encouraged to
periodically attempt stopping
DDAVP.
2. Patients with a diagnosis
of hemophilia or Von
Willebrands disease will be
exempt from prior
authorization.
Use PA Form# 20420
ANTISPASMODICS
MC/DEL
MC
ANTISPASMODICS - LONG ACTING
OXYBUTYNIN
MC/DEL
8
DETROL TABS
URISPAS TABS
MC/DEL
8
DITROPAN
MC/DEL
9
TROSPIUM
MC
MC/DEL
8
8
DITROPAN XL TBCR
MC/DEL
MC/DEL
8
MYRBETRIQ
OXYTROL
MC/DEL
8
MC/DEL
9
MC/DEL
OXYBUTYNIN ER TABS
MC/DEL
TOVIAZ
MC
VESICARE1
8
ENABLEX1,3
TOLTERODINE TAB
2
DETROL LA CP
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
1. See Criteria Section.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Product is considered line
extension of the original
product due to Healthcare
Reform (HCR). MaineCare
will consider these
medications non-preferred
and a step 9 because of the
impact under the Federal
Rebate Program in
conjunction with HCR.
1. Vesicare 5mg and Enablex 7.5mg maximum doses if given with drugs known to be significant CYP3A4 inhibitors.(Ketoconazole, Sporanox, Erythromycin, Fluconazole, Nefazodone,
Nelfinavir, and Ritonavir)
DDI: Enablex 15mg and Vesicare 10mg will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following medications:
clarithromycin, erythromycin, Ketek, Crixivan, Norvir, ketoconazole, fluconazole (except 150mg strength), Sporanox. nefazodone, or diltiazem.
3. Use a preferred long
acting antispasmodic.
CHOLINERGIC
HERED. TYROSINEMIA
MC/DEL
URECHOLINE
MC/DEL
BETHANECHOL
Use PA Form# 20420
METABOLIC MODIFIER
MC
ORFADIN
Use PA Form# 20420
ANTIHYPERTENSIVES / CARDIAC
Page 13 of 58
Approved for Type 1 hereditary tyrosinemia patients. Must include laboratory evidence of dx at first PA.
CARDIAC GLYCOSIDES
MC/DEL
DIGITEK TABS
MC/DEL
DIGOXIN
MC/DEL
LANOXIN
Use PA Form# 20420
CARDIAC - SINUS NODE INHIBITORS
MC
ANTIANGINALS--Isosorbide Di-nitrate/
Mono-Nitrates
MC/DEL
ISOSORBIDE MONONITRATE TABS
MC
DILATRATE SR CPCR
MC/DEL
ISOSORBIDE MONONITRATE ER
MC
ISORDIL TABS
MC
ISORDIL TITRADOSE TABS
MC
ISOSORBIDE DINITRATE SUBL
MC/DEL
ISOSORBIDE DINITRATE TABS
MC/DEL
ISOSORBIDE DINITRATE CR TBCR
MC/DEL
ISOSORBIDE DINITRATE ER TBCR
MC/DEL
ISOSORBIDE DINITRATE TD TBCR
MC/DEL
IMDUR TB24
MC/DEL
ISMO TABS
CORLANOR
In patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤35%, who are in sinus rhythm with resting heart rate ≥70 beats per
minute (bpm) and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use
MC
NITRO - OINTMENT/CAP/CR
MC/DEL
NITROBID OINT
MC/DEL
NITROGLYCERIN CPCR
MC
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MONOKET TABS
Use PA Form# 20420
NITROL OINT
MC
NITRO - PATCHES
Use PA Form# 20420
NITRO-TIME CPCR
MC/DEL
1
NITROGLYCERIN PT241
MC/DEL
1
NITREK PT241
MC/DEL
1
NITRO-DUR PT 24 0.8MG1
MC
3
MINITRAN PT24
MC
NITRODISC PT24
MC/DEL
NITRO-DUR PT24
NITROQUICK SUBL
1
1. At least 2 step 1's and
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
step 3 of the preferred
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
products must be used in
preferred drug(s) exists.
specified order or PA will be
required.
Use PA Form# 20420
NITRO - SUBLINGUAL/ SPRAY
BETA BLOCKERS - NON SELECTIVE
MC/DEL
NITROSTAT SUBL
MC/DEL
MC/DEL
NITROTAB SUBL
MC
NITROLINGUAL SOLN
MC
NITROLINGUAL TABS
MC/DEL
MC
CARVEDILOL
INNOPRAN XL
MC
MC/DEL
BETAPACE TABS
BETAPACE AF TABS
LEVATOL TABS
MC
MC/DEL
MC/DEL
NADOLOL TABS
MC/DEL
MC/DEL
MC/DEL
PINDOLOL TABS
MC/DEL
COREG TABS
CORGARD TABS
PROPRANOLOL HCL SOLN1
MC/DEL
INDERAL TABS
MC/DEL
MC/DEL
PROPRANOLOL HCL TABS1
PROPRANOLOL HCL 60MG TABS
MC/DEL
PROPRANOLOL LA CAPS
MC
MC/DEL
BETA BLOCKERS - CARDIO SELECTIVE
BETA BLOCKERS - ALPHA / BETA
MC
COREG CR3
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Recommend using BID
since its effects do not last
24 hours.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Please use other
strengths in combination to
obtain this dose.
INDERAL LA CPCR
3. Dosing limits still apply.
Please see dose
consolidation list
RANEXA
MC/DEL
SOTALOL AF
SOTALOL HCL TABS
MC/DEL
TIMOLOL MALEATE TABS
MC/DEL
ACEBUTOLOL HCL CAPS
MC/DEL
MC/DEL
ATENOLOL TABS1
BETAXOLOL HCL TABS
MC/DEL
BISOPROLOL FUMARATE TABS
MC
MC/DEL
MC/DEL
TENORMIN TABS
MC/DEL
METOPROLOL TARTRATE TABS1
METOPROLOL ER
MC/DEL
TOPROL XL TB24
MC/DEL
ZEBETA TABS
MC/DEL
LABETALOL HCL TABS
Use PA Form# 20420
MC/DEL
MC
MC/DEL
MC
BYSTOLIC
KERLONE TABS
LOPRESSOR TABS
SECTRAL CAPS
1. Recommend using
Atenolol (and metoprolol)
BID since its effects do not
last 24 hours.
Use PA Form# 20420
TRANDATE TABS
Use PA Form# 20420
BETA BLOCKERS & DURECTIC COMBOS
MC/DEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DUTOPROL
Use PA Form# 20420
Page 14 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
CALCIUM CHANNEL BLOCKERS-Amlodipines, Bepridil, Diltiazems,
Felodipines, Isradipines, Nifedipines,
Nisoldipine, and Verapamils
MC/DEL
AMLODIPINE
MC/DEL
DILTIA XT CP24
MC/DEL
5
DILACOR XR CP241
MC/DEL
DILTIAZEM HCL ER CP24
MC/DEL
6
TAZTIA1
MC/DEL
DILTIAZEM HCL XR CP24
MC
8
CARDIZEM TABS1
MC/DEL
DILTIAZEM CD 300MG CP24
MC
8
CARDIZEM CD CP241
MC/DEL
DILTIAZEM CD 360MG CP24
MC
8
CARDIZEM LA TB24
CARTIA XT CP241
MC
8
CARDIZEM SR CP121
MC/DEL
8
DILTIAZEM HCL TABS1
MC/DEL
8
DILTIAZEM HCL ER CP12
MC/DEL
8
DILTIAZEM HCL ER CP121
1
1
1. Dosing limits apply,
please see dose
consolidation list.
NORVASC TABS
Use PA Form# 20420
MC
MC
MC/DEL
DILTIAZEM CD CP241
MC/DEL
DILTIAZEM HCL ER CP24
MC/DEL
DILTIAZEM XR CP24
MC/DEL
TIAZAC CP24
1
1
1. Products must be used in
specified order or PA will be
required. Just write
"Diltiazem 24-hour"and the
pharmacy will use a
preferred long acting
diltiazem that does not
require PA.
1
DDI: All preferred diltiazems will now be non-preferred and require prior authorization if they are currently being used in combination with either Enablex 15mg or Vesicare 10mg. All
non-preferred diltiazems require prior authorization, but with any prior authorization request, the member's drug profile will also be monitored for current use with Enablex 15mg or
Vesicare 10mg.
1
1
Use PA Form# 20420
MC/DEL
PLENDIL TB24
MC/DEL
FELODIPINE
Use PA Form# 20420
MC
DYNACIRC CAPS
MC
DYNACIRC CR TBCR
MC
CARDENE SR CPCR
MC
NICARDIPINE HCL CAPS
1
Other Preferred calcium channel blockers must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
Use PA Form# 20420
1. Established users will be on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
grandfathered
Use PA Form# 20420
Other Preferred calcium channel blockers must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists.
1. Established users of
Adalat CC are
grandfathered.
Preferred drug must be tried and failed in step order due to lack of efficacy or intolerable side effects before non-preferred drugs in step order will be approved, unless an acceptable
clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists.
AFEDITAB CR
NIFEDIAC CC
MC/DEL
ADALAT CC TBCR1
MC/DEL
MC/DEL
NIFEDIPINE CAPS
MC/DEL
NIFEDICAL XL TBCR
MC/DEL
PROCARDIA CAPS
MC/DEL
NIFEDIPINE TBCR
MC/DEL
PROCARDIA XL TBCR
Use PA Form# 20420
MC/DEL
NIFEDIPINE ER TBCR
MC
SULAR TB24
MC
SULAR CR1
1. Established users of
10MG and 20MG strengths
are grandfathered.
MC/DEL
Preferred drugs must be tried and failed (in step-order) due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Use PA Form# 20420
MC/DEL
1
VERAPAMIL HCL CR TBCR
MC/DEL
CALAN TABS
MC/DEL
1
VERAPAMIL HCL ER TBCR
MC/DEL
CALAN SR TBCR
MC/DEL
1
VERAPAMIL HCL SR TBCR
MC/DEL
COVERA-HS TBCR
MC
ANTIARRHYTHMICS
VERAPAMIL HCL ER CP24
MC/DEL
VERAPAMIL HCL SR CP24
MC/DEL
VERAPAMIL HCL TABS
MC/DEL
VERELAN CP24
MC/DEL
VERELAN PM CP24
Use PA Form# 20420
MC/DEL
MC/DEL
AMIODARONE HCL
MC/DEL
CORDARONE
FLECAINIDE
MC/DEL
DISOPYRAMIDE
1. Prescription must be
written by Cardiologist.
MC/DEL
MEXILETINE HCL
NORPACE
MC/DEL
MC/DEL
MULTAQ
MC/DEL
MC/DEL
PROCAINAMIDE
MC
QUINIDEX
MC/DEL
PROPAFENONE
MC/DEL
TAMBOCOR
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
PACERONE
QUINAGLUTE
MC/DEL
TIKOSYN1
MC/DEL
QUINIDINE GLUCONATE
MC/DEL
RYTHMOL SR
MC/DEL
QUINIDINE SULFATE
MC/DEL
RYTHMOL
MC/DEL
BENAZEPRIL HCL
MC
5
MAVIK TABS
MC/DEL
CAPTOPRIL TABS
MC/DEL
5
ACCUPRIL TABS
MC/DEL
ENALAPRIL MALEATE TABS
MC/DEL
8
ACEON TABS1
MC/DEL
FOSINOPRIL SODIUM
MC/DEL
8
ALTACE CAPS1
MC/DEL
LISINOPRIL TABS
MC/DEL
8
LOTENSIN TABS1
MC
ACE INHIBITORS
ISOPTIN-SR
MC/DEL
Products must be used in
Preferred drugs must be tried and failed (in step-order) due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
specified order or PA will be exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
required. Just write
another drug and the preferred drug(s) exists.
"Verapamil 24-hour" and the
pharmacy will use a
preferred long acting generic
that does not require PA.
Use PA Form# 20420
DDI: Amiodarone will now be non-preferred and require prior authorization if it is currently being used in combination with either Lovastatin (doses greater than 40mg/day) or Lipitor
(doses greater than 20mg/day) or Levofloxacin or Gemifloxacin, or Moxifloxacin, or Ofloxacin.
DDI: Multaq will be preferred unless the following medications are seen in the member’s drug profile within the last 35 days for brand name medications or 90 days for generic
medications: Erythromycin, Amiodarone and other antiarrhythmics, TCA’s, Phenothiazine, Ketoconazole, Itraconazole, Voriconazole, Cyclosporine, Telithromycin, Clarithromycin,
Nefazodone, Ritonavir.
1. Non-preferred products
must be used in specified
order.
Use PA Form# 20420
Page 15 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists. Non-preferred products are subject to step-order requirements unless clinical circumstances warrant exception.
MC/DEL
MC/DEL
ANGIOTENSIN RECEPTOR BLOCKER
RAMIPRIL
QUINAPRIL HCL
MC/DEL
BENICAR TABS
MC/DEL
DIOVAN
IRBESARTAN1
MC/DEL
MC/DEL
MC/DEL
1
1
LOSARTAN
1
MICARDIS TABS1
1
MC/DEL
8
MOEXIPRIL HCL
MC
8
MONOPRIL HCT TABS
MC/DEL
8
PRINIVIL TABS
MC/DEL
8
UNIVASC
MC
8
VASOTEC TABS
1
1
1
1
1
MC/DEL
8
ZESTRIL TABS
MC/DEL
8
ATACAND TABS
MC/DEL
AVAPRO
MC/DEL
8
8
MC/DEL
8
EDARBI
MC
8
TEVETEN TABS
MC/DEL
8
TRIBENZOR
COZAAR
Use PA Form# 20420
1. Preferred products only
available without PA if
patient on diabetic therapy
or prior ACE therapy.
The initial criteria to use any ARB is that the member must have failed ACE inhibitors (such as due to coughing) in the past or must currently be actively treated for diabetes and
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2
2. Use preferred active
ingredients which are
available without PA.
DIRECT RENIN INHIBITOR
MC/DEL
AMTURNIDE
MC/DEL
MC/DEL
TEKTURNA1
TEKAMLO
1. Must show failure of
single and combination
therapy from all preferred
antihypertensive categories.
Use PA Form# 20420
ANTIHYPERTENSIVES - CENTRAL
MC/DEL
CATAPRES-TTS
MC/DEL
CATAPRES TABS
MC/DEL
CLONIDINE HCL TABS
MC/DEL
CLONIDINE TTS
MC/DEL
GUANFACINE HCL TABS
MC
GUANABENZ ACETATE TABS
MC/DEL
HYDRALAZINE HCL TABS
MC
ISMELIN TABS
MC
HYLOREL TABS
MC/DEL
METHYLDOPA TABS
MC/DEL
MINOXIDIL TABS
MC/DEL
PRAZOSIN HCL CAPS
MC/DEL
RESERPINE TABS
ACE INHIBITORS AND CA CHANNEL
BLOCKERS
MC/DEL
NEXICLON
MC/DEL
MC/DEL
MC/DEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MINIPRESS CAPS
MC
MC/DEL
MC
Use PA Form# 20420
TENEX TABS
8
AMLODIPINE/BENAZEPRIL
8
9
TARKA TBCR
AMLODIPINE/BENAZEPRIL
9
LOTREL CAPS
Use individual preferred
generic medications.
Use PA Form# 20420
ACE AND THIAZIDE COMBO'S
BETA BLOCKERS AND DIURETIC
COMBO'S
ARB'S AND CA CHANNEL BLOCKERS
MC/DEL
BENAZEPRIL HCL/HYDROCHLOR
ACCURETIC TABS
MC/DEL
CAPTOPRIL/HYDROCHLOROTHIA
ENALAPRIL MALEATE/HCTZ TABS
MC/DEL
MC
MC/DEL
MC/DEL
PRINZIDE TABS
MC/DEL
LISINOPRIL-HCTZ TABS
MC/DEL
UNIRETIC TABS
MC/DEL
LOTENSIN HCT TABS
MC/DEL
ZESTORETIC TABS
ATENOLOL/CHLORTHALIDONE
MC/DEL
CORZIDE TABS
MC/DEL
BISOPROLOL FUMARATE/HCTZ
MC/DEL
LOPRESSOR HCT TABS
MC/DEL
PROPRANOLOL/HCTZ
AZOR
MC/DEL
EXFORGE1
MC/DEL
EXFORGE HCT1
MC/DEL
BENICAR HCT
MC/DEL
MC/DEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
VASERETIC TABS
MC
MC/DEL
MC/DEL
Use PA Form# 20420
MONOPRIL HCT TABS
MC
TENORETIC
MC
TIMOLIDE 10/25 TABS
MC/DEL
ZIAC TABS
MC/DEL
TWYNSTA
1. Preferred products only
available without PA if
patient on diabetic therapy
or prior ACE therapy.
Use PA Form# 20420
ARB'S AND DIURETICS
MC/DEL
1
LOSARTAN HCT1
MC/DEL
MC/DEL
7
8
IRBESARTAN HYDROCHLOROTHIAZIDE
ATACAND HCT TABS
MICARDIS HCT TABS1
VALSARTAN-HYDROCHLOROTHIAZIDE1
MC
8
AVALIDE TABS1
MC/DEL
8
MC/DEL
8
DIOVAN HCT TABS1
HYZAAR TABS
MC
8
TEVETEN HCT TABS
1. Preferred products only
available without PA if
patient on diabetic therapy
or prior ACE therapy.
Use PA Form# 20420
Page 16 of 58
Same initial criteria as the ARB class and Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless
an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
interaction between another drug and the preferred drug(s) exists.
ANGIOTENSIN MODULATORS-ARB
COMBINATION
MC/DEL
MC
ENTRESTO
Use PA Form# 20420
ARB'S AND DIRECT RENIN INHIBITOR
COMBINATION
MC/DEL
VALTURNA
Use PA Form# 20420
1. Multiples of
Spironolactone 25 mg are
cheaper than 50 mg
strength. Inspra will be
approved for severe breast
tenderness and male
gynecomastia.
DIURETICS
EDARBYCLOR
MC/DEL
ACETAZOLAMIDE TABS
MC/DEL
ALDACTAZIDE TABS
MC/DEL
BUMETANIDE
MC/DEL
ALDACTONE TABS
MC/DEL
CHLOROTHIAZIDE TABS
MC/DEL
AMILORIDE HCL
MC/DEL
CHLORTHALIDONE TABS
MC/DEL
BUMEX TABS
MC
EDECRIN TABS
MC/DEL
DEMADEX TABS
MC/DEL
EDECRIN TABS
MC/DEL
DIAMOX
MC/DEL
HYDROCHLOROTHIAZIDE
MC
DIURIL
MC/DEL
INDAPAMIDE TABS
MC/DEL
METHAZOLAMIDE TABS
MC/DEL
METHYCLOTHIAZIDE TABS
MC/DEL
INSPRA
MC/DEL
SPIRONOLACTONE 25MG TABS
MC/DEL
LASIX TABS
MC/DEL
SPIRONOLACTONE/HYDRO
MC/DEL
MAXZIDE
MC/DEL
TORSEMIDE TABS
MC/DEL
MICROZIDE CAPS
MC/DEL
TRIAMTERENE/HCTZ
MC/DEL
MIDAMOR TABS
MC
MC/DEL
DYAZIDE CAPS
MC
ENDURON TABS
MC
ZAROXOLYN TABS
CCB / LIPID
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
NAQUA TABS
MC/DEL
SPIRONOLACTONE 50MG1
MC/DEL
CADUET
NEUROGENIC ORTHOSTATIC HYPOTENSION
NEUROGENIC ORTHOSTATIC
HYPOTENSION
MC
NORTHERA
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
LIPID DRUGS
CHOLESTEROL - BILE SEQUESTRANTS
MC/DEL
CHOLESTYRAMINE
MC/DEL
COLESTID
MC/DEL
COLESTIPOL HCI
MC/DEL
PREVALITE
MC
QUESTRAN
MC/DEL
CHOLESTEROL - FIBRIC ACID
DERIVATIVES
CHOLESTEROL - HGM COA + ABSORB
INHIBITORS MORE POTENT
DRUGS/COMBINATIONS
FENOFIBRATE
MC/DEL
GEMFIBROZIL TABS
MC/DEL
LOPID
MC/DEL
NIASPAN
MC
TRILIPIX
MC/DEL
MC/DEL
FENOFIBRATE 120mg
FIBRICOR
MC/DEL
MC/DEL
ATORVASTATIN
CRESTOR
SIMVASTATIN1
VYTORIN
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
WELCHOL TABS
MC/DEL
MC/DEL
Use PA Form# 20420
MC
ANTARA
MC
LIPOFEN
MC/DEL
LOFIBRA
MC
TRICOR
MC
TRIGLIDE
MC/DEL
LIPITOR
MC
MC/DEL
MC/DEL
LIPTRUZET
ZOCOR
SIMVASTATIN 80MG
DDI: Fenofibrate is preferred but will require a prior authorization requests if used concurrent with Warfarin.
DDI: Gemfibrozil will now be non-preferred and require prior authorization if it is currently being used with any of the following medications: Prandin, Actos, Avandia, any Avandia/Actos
combination product, any HMG-COA Reductase Inhibitors (statins), or Warfarin.
1,2
1. Dosing limits apply,
please see dosage
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Current users
grandfathered.
DDI: Lipitor (doses greater than 20mg/day) will now be non-preferred and require prior authorization if they are currently being used in combination cyclosporine.
MC
DDI: Lipitor (doses greater than 20mg/day) will now be non-preferred and require prior authorization if it is currently being used in combination with Amiodarone.
CHOLESTEROL - HGM COA + ABSORB
INHIBITORS LESS POTENT
DRUGS/COMBINATIONS
MC/DEL
LESCOL CAPS
MC
8
MC/DEL
LESCOL XL TB24
MC
8
ALTOPREV TB24
LIVALO
MC/DEL
LOVASTATIN TABS2
MC/DEL
8
MEVACOR TABS
MC/DEL
PRAVASTATIN2
ZETIA TABS
MC/DEL
8
PRAVACHOL TABS
MC/DEL
8
PRAVIGARD
MC
Use PA Form# 20420
DDI: All preferred statins will now be non-preferred and require prior authorization if it is currently being used in combination with Gemfibrozil.
2. Dosing limits apply,
please see dosage
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Zetia will be approved for patients unable to tolerate all other therapies or unable to achieve cholesterol goal with maximally tolerated dose of most potent
statins.
DDI: Lescol will now be non-preferred and require prior authorization if it is currently being used in combination with diclofenac.
DDI: Lovastatin (doses greater than 40mg/day) will now be non-preferred and require prior authorization if it is currently being used in combination with Amiodarone.
Page 17 of 58
DDI: Lovastatin (doses greater than 20mg per day) will now be non-preferred and require prior authorization if it is currently being used in combination cyclosporine.
Use PA Form# 20420
CHOLESTEROL - HGM COA + ABSORB
INHIBITORS STATIN/ NIACIN COMBO
MC
SIMCOR
FAMILIAL HYPERCHOLESTEROLEMIA
MC
ADVICOR TBCR
Use PA Form# 20420
MC
JUXTAPID
MC
KYNAMRO1
1. Clinical PA required for
appropriate diagnosis
MC/DEL
MC
PRALUENT1,2,3
2. Quantity limits apply for
HeFH/ASCVD 1 injection
per 14 days for HoFH 3
injectors per 30 days
REPATHA1,2,3
DDI: All preferred statins will now be non-preferred and require prior authorization if it is currently being used in combination with Gemfibrozil.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists
Juxtapid is contraindicated with strong CYP3A4 inhibitors. Juxtapid dosage should not exceed 30mg daily when it is used concomitantly with weak CYP3A4 inhibtors.
Kynamro requires an appropriate lab testing prior to starting (ALT<AST), Alkaline phosphatase and total billrubin, monthly liver-related tests for the first year, then every three months.
3. Documented adherence
to lipid lowering medications
and abstinence from
Praluent and Repatha initial approvals will be limited to 8 weeks (for HeFH or ASCVD) or 3 months (for HoFH). Baseline and follow up lipid profiles are required and subsequent
tobacco for previous 90
approvals will require additional levels being done to assess changes. Will not approve if LDL-C is not at goal after a period of : 1. 24 weeks for Praluent or Repatha for treatment of
days
HeFH/ASCVD 2. 3 months of Repatha for treatment of HoFH)
For Repatha and Praluent
please use PA form #10800
Use PA Form#10500
PULMONARY ANTI-HYPERTENSIVES
MC/DEL
MC
SILDENAFIL4
PULMONARY ANTI-HYPERTENSIVES
ADEMPAS6,7
MC/DEL
EPOPROSTENOL INJ6
MC/DEL
2
MC
VENTAVIS
MC
MC
ADCIRCA1
MC
MC
MC/DEL
MC
1. See Criteria Section.
FLOLAN6
OPSUMIT7,8
2. See Criteria Section.
ORENITRAM
4. See Criteria Section.
REMODULIN6
5. There will be dosing limits
of one 20ml multidose vial/
30 days supply without pa.
3. See Criteria Section.
REVATIO3
UPTRAVI
6. PA is required to establish
and conform who group 1
diagnosis of primary PAH
(Primary Pulmonary
Hypertension) and NYHA
functional class 3 & 4.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significat potential drug interation between another drug and the
preferred drug(s) exists.
1. Adcirca approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 2 or 3.
2. Ventavis approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 3 or 4.
3. Revatio approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 2 or 3.
3. Revatio approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 2 or 3.
4. Sildenafil will be preferred with clinical PA for treatment of pulmonary arterial hypotenion (WHO Group 1) in adults to improve exercise ability and delay clinical worsening.
DDI: Opsumit will require a prior authorization if it is currently being used in combination with drugs known to be significant CYP3A4 inhibitors (ketoconazole, itraconazole,
clarithromycin, indinavir, nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
7. Requires previous
trials/failure of multiple
preferred medications.
DDI: Adempas will require a prior authorization if it is currently being used in combination with drugs known to be PDE inhibitors should be avoided (including dypyridamole, adcira and
tadalafil) with adempas
8. Dosing limits apply,
please see the dose
consolidation list.
DDI: Uptravi will require a prior authorization if it is currently being used in combination with strong inhibitors of CYP2C8 (gemfibrozil)
Use PA Form# 20420
ERA / ENDOTHELIN RECEPTOR
ANTAGONIST
MC
LETAIRIS1,2
MC
TRACLEER3,4
Page
1. Providers must be
registered with LEAP
Prescribing program, a
restricted
distribution
18
of 58
program.
Tracleer approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and NYHA functional class 2 thru 4.
ERA / ENDOTHELIN RECEPTOR
ANTAGONIST
1. Providers must be
registered with LEAP
Prescribing program, a
restricted distribution
program.
DDI: Preferred Oral Contraceptives will now be non-preferred and require prior authorization if it is currently being used in combination with Tracleer.
2. Clinical PA is required to Letairis approvals will require WHO Group 1 diagnosis of primary PAH (Primary Pulmonary Hypertension) and functional class 2 or 3 symptoms.
establish diagnosis and
medical necessity.
3. Prior trial of Letaris, WHO
Group 1 diagnosis of PAH
(Primary Pulmonary
Hypertension) and NYHA
functional class of 3.
4. For members with NYHA
functional class of 4,
Tracleer approval will be
allowed with confirmation of
diagnosis and functional
class.
Use PA Form# 20420
IMPOTENCE AGENTS
IMPOTENCE AGENTS
As of January 1, 2006, per
CMS (federal govt.),
impotence agents are no
longer covered.
As of January 1, 2006, per CMS (federal govt.), impotence agents are no longer covered.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Approvals will require
diagnosis of chemo-induced
nausea/vomiting and failed
trials of all preferred antiemetics, including 5-HT3
class (Ondansetron) and
Marinol.
Preferred drugs and step therapy must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists. * Ondansetron limits still apply as listed on the Ondansetron PA form for covered indications including chemotherapy, radiotherapy, post
operative nausea & vomiting and hyperemesis gravidarum. Other medical indications will be approved or denied on a case by case basis. Hyperemesis and other medical indications
approved are still subject to failure of multiple preferred antiemesis drugs.
ANTI-EMETOGENICS
ANTIEMETIC - ANTICHOLINERGIC /
DOPAMINERGIC
MC/DEL
MECLIZINE HCL TABS
MC
ANTIVERT TABS
MC
PROMETHAZINE SUPP
MC
PHENERGAN SOLN
PROMETHAZINE
MC
PROMETHAZINE 50MG SUPP
TRANSDERM-SCOP PT72
MC
PROMETHEGAN SUPP
MC/DEL
MC
TORECAN TABS
MC
ANTIEMETIC - 5-HT3 RECEPTOR
ANTAGONISTS/ SUBSTANCE P
NEUROKININ
MC/DEL
5
GRANISETRON
8
8
AKYNZEO1
ONDANSETRON ODT TBDP2,4
MC
MC
ONDANSETRON INJ2,4
MC
8
ANZEMET TABS
MC
8
CESAMET1
MC
MC
8
8
DICLEGIS
MC/DEL
8
EMEND3
KYTRIL
MC/DEL
8
MARINOL CAPS
MC
8
SANCUSO
MC
MC/DEL
MC/DEL
8
8
VARUBI
8
ZOFRAN TABS4
MC/DEL
8
ZOFRAN INJ4
3. Clinical PA is required for
members on highly emetic
anti-neoplastic agents.
MC
8
ZUPLENZ
4. Dosing limits apply,
please see Dosage
Consolidation List
MC/DEL
DRONABINOL CAPS
MC/DEL
ONDANSETRON TABS2,4
MC/DEL
MC/DEL
ALOXI
ZOFRAN ODT TBDP4
Akynzeo- Concomitant use should be avoided in patients who are chronically using a strong CYP3A inducer such as rifampin.
Varubi – Available to the few who are unable to tolerate or who have failed on preferred medications
2. Ondansetron will be
preferred with CA diag and
dosing limits still apply.
Use PA Form# 20610 for
Ondansetron requests
Use PA Form# 20420 for all
others
NON-SEDATING ANTIHISTAMINES / DECONGESTANTS
Page 19 of 58
ANTIHISTIMINES - NON-SEDATING
MC
MC/DEL
ALAVERT TABS
MC
5
CLARINEX TABS1,5
5
CLARINEX SYR
5
FEXOFENADINE
1
ZYRTEC
1,2
MC
CLARITIN (OTC)
MC
MC/DEL
MC
CLARITIN SYRP (OTC)
MC/DEL
5
LORATADINE
MC/DEL
5
TAVIST ND (OTC)
MC/DEL
8
ZYRTEC SYR
ALLEGRA3
MC
8
CLARITIN3
MC/DEL
MC/DEL
8
DESLORATADIN
8
MC/DEL
MC/DEL
8
LORATADINE ODT4
LEVOCETIRIZINE4
9
XYZAL
MC/DEL
MC
CETIRIZINE TABS
1
1. Must fail preferred drugs, Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved (in step order), unless an acceptable clinical
OTC loratidine and cetirizine exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
before moving to nonanother drug and the preferred drug(s) exists. No combination product with decongestant will be approved since pseudoephedrine available without PA.
preferred step order drugs.
1,2
3
2. Clarinex and Zyrtec syrp
<6 yr w/o PA.
Pseudoephedrine is available with prescription.
3. Must fail all step 5 drugs
(Clarinex, Fexofenadine and
Zyrtec) before moving to
next step product.
4. All OTC versions of
loratadine ODT are now nonpreferred.
5. Pa's for Clarinex
RediTabs will only be
approved if between the
ages of 6-11 years old.
Use PA Form# 20530
ANTIHISTIMINES - OTHER
MC/DEL
CLEMASTINE
MC/DEL
CHLORPHENIRAMINE
MC/DEL
DIPHENHYDRAMINE
MC/DEL
AUVI- Q
EPIPEN
Use PA Form# 20530
ALLERGY / ASTHMA THERAPIES
ANAPHYLACTIC DEVICES
MC/DEL
ALLERGEN IMMUNOTHERAPY
MC
TWINJECT
MC/DEL
GRASTEK
MC/DEL
RAGWITEK
MC
ORALAIR1
1
Use PA Form# 20420
1
Prescriber must provide the testing to show that the patient is allergic to the components in the prescribed therapy and must provide a clinically valid rationale why single agent
sublingual therapy is being chosen over subcutaneous therapy
1. See criteria section
Treatment must start 12 weeks before expected onset of pollen season and only after confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies for short
ragweed pollen (Ragwitek), timothy grass or cross-reactive grass pollens (Grastek), or any of the 5 grass species contained in Oralair
Have an auto-injectable epinephrine on-hand
Grastek : Patient age ≥5 years and ≤65 years
Ragwitek: Patient age ≥18 years and ≤65 years
Oralair: Patient age ≥10 years and ≤65 years
ANTIASTHMATIC - ANTICHOLINERGICS INHALER
MC/DEL
SPIRIVA HANDIHALER1,2
MC/DEL
MC/DEL
SPIRIVA RESPIMAT
TUDORZA
MC/DEL
INCRUSE ELLIPTA3
Use PA Form# 20420
1. Quantity limit of 1
inhalation daily (1 capsule Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
for inhalation daily) Spiriva on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
will require PA if Combivent preferred drug(s) exists.
or Atrovent nebulizer
solution is in member's
current drug profile.
Page 20 of 58
2. We ask physicians to
write "asthma" on the
prescription whenever
Spiriva is primarily being
used for that condition.
3. Quantity limit of 1
inhalation daily
ANTIASTHMATIC PHOSPHODIESTERASE 4 INHIBITORS
MC/DEL
ANTIASTHMATIC - ANTICHOLINERGICS NEBULIZER
MC/DEL
IPRATROPIUM BROMIDE SOLN
ANTIASTHMATIC - ANTIINFLAMMATORY
AGENTS
MC/DEL
CROMOLYN SODIUM NEBU
ANTIASTHMATIC - NASAL STEROIDS
MC/DEL
FLUTICASONE SPR
MC/DEL
OMNARIS SPR3
3
ZETONNA
MC
MC/DEL
MC/DEL
DALIRESP
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
ATROVENT SOLN
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
NUCALA2
1. Need max inhaled
steroids and written by
pulmonary or allergy
specialist.
2. For patients with severe
asthma aged 12 years or
older
Nucala & Xolair approval will require suboptimal response to maximal doses of inhaled steroid as evidenced by asthmatic ER/Hospital admissions and Allergy/Pulmonary specialist
management.
XOLAIR1
Use PA Form# 20420
MC/DEL
ANTIASTHMATIC - NASAL MISC.
MC/DEL
3
CROMOLYN NASAL 4%
MC/DEL
5
BECONASE AQ INHA1,3
MC/DEL
MC/DEL
8
DYMISTA
8
FLONASE SUSP2,3
MC/DEL
MC/DEL
8
8
FLUNISOLIDE SOLN1,3
NASONEX SUSP
MC
MC
8
QNASL
8
RHINOCORT AERO2,3
MC/DEL
8
RHINOCORT AQUA SUSP2,3
MC
MC
MC/DEL
8
TRI-NASAL SOLN2,3
8
VANCENASE POCKETHALER AERS2,3
8
VERAMYST2,3
MC/DEL
9
TRIAMCINOLONE NS
MC
7
ATROVENT NASAL SOL
MC/DEL
7
7
ASTELIN
8
ASTEPRO2
8
PATANASE
MC
MC/DEL
MC/DEL
IPRATROPIUM NASAL SOL1
Use PA Form# 20420
1. All preferred drugs must
be tried before moving to
non preferred steps.
Preferred drugs and step therapy must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
2. All step 5 medications
need to be tried before
moving to step 8's.
3. Dosing limits apply to
whole category, please see
dosage consolidation list.
Use PA Form# 20420
1. Ipratropium will be
approved if submitted with
documentation supporting
use of CPAP machine.
Approved if patient fails on nonsedating antihistamines and steroid nasal sprays.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Utilize Multiple preferred,
as well as step therapy
Astelin.
ANTIASTHMATIC - BETA ADRENERGICS
MC/DEL
ALBUTEROL NEB
MC/DEL
ACCUNEB NEBU
MC/DEL
FORADIL AEROLIZER CAPS
MC/DEL
ALBUTEROL AER
MC/DEL
METAPROTERENOL
MC/DEL
ALBUTEROL HFA
MC/DEL
PROVENTIL HFA
MC/DEL
ALBUTEROL 0.63mg/3ml
MC/DEL
SEREVENT
MC/DEL
MC/DEL
TERBUTALINE SULFATE TABS
MC/DEL
ARCAPTA3
BRETHINE
MC
MC
MC/DEL
PROAIR HFA
3
PROAIR RESPICLICK
MC/DEL
STRIVERDI
VENTOLIN AERS
MC/DEL
MC
VENTOLIN HFA AERS3
VOLMAX TBCR
1. Xopenex users w/ prior
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
asthma hospitalization due on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
to albuterol nebulizer failure preferred drug(s) exists.
will be grandfathered.
2. Quantity Limit: 12
cc/day.
3. Dosing limits apply,
please see dosage
consolidation list.
Page 21 of 58
MC
VOSPIRE ER TB12
MC
XOPENEX HFA
MC
XOPENEX NEBU
3
1,2
Use PA Form# 20420
ANTIASTHMATIC - ADRENERGIC
COMBINATIONS
2,3
MC/DEL
ADVAIR HFA1,2
MC/DEL
BREO ELLIPTA
MC/DEL
DULERA
MC/DEL
ADVAIR DISKUS2,3
MC/DEL
SYMBICORT
1. We ask physicians to
write "asthma" on the
prescription whenever
Advair is primarily being
used for that condition.
2
ADVAIR DISKUS- Patients currently using Advair Diskus® will have a 90 day grace period to transition to Advair HFA® or another preferred product on the PDL such as Dulera® or
Symbicort® Advair Diskus will be approved for patients with asthma or COPD who: have difficulty using MDIs due to lack of hand-breath coordination AND/OR have a history or
develop thrush with MDI formulations of inhaled corticosteroids AND/OR are 4-11 years old.
2. Dosing limits apply,
please see dosage
consolidation list.
3. Clinical PA required for
appropriate diagnosis
Use PA Form# 20420
ANTIASTHMATIC - ADRENERGIC
ANTICHOLINERGIC
MC/DEL
ALBUTEROL/IPRATROPIUM NEB. SOLN
MC/DEL
ANORO ELLIPTA
MC/DEL
MC/DEL
COMBIVENT RESPIMAT
MC/DEL
DUONEB SOLN1
STIOLTO
MC/DEL
THEO-24 CP24
1. Please use preferred
individual ingredients
Albuterol and Ipratropium.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Duoneb components are available separately without PA.
Use PA Form# 20420
ANTIASTHMATIC - XANTHINES
ANTIASTHMATIC - STEROID INHALANTS
MC/DEL
AMINOPHYLLINE TABS
MC/DEL
THEOCHRON TB12
MC
THEOLAIR TABS
MC/DEL
THEOLAIR-SR TB12
MC/DEL
UNIPHYL TBCR
MC/DEL
THEOPHYLLINE CR TB12
MC
THEOPHYLLINE ELIX
MC/DEL
THEOPHYLLINE SOLN
MC/DEL
THEOPHYLLINE ER CP12
MC/DEL
THEOPHYLLINE ER TB12
MC/DEL
ASMANEX4,5
MC/DEL
FLOVENT DISKUS
MC/DEL
MC/DEL
FLOVENT HFA
PULMICORT FLEXHALER
MC/DEL
PULMICORT SUSP1,4
4
4
Use PA Form# 20420
MC/DEL
5
AEROBID AERS2,4
MC
5
BECLOVENT AERS2,4
MC
5
VANCERIL AERS
MC/DEL
8
AEROBID-M AERS3,4
MC/DEL
8
ALVESCO4
2,4
MC
QVAR AERS
MC/DEL
8
ARNUITY ELLIPTA
MC
AEROSPAN
MC/DEL
MC
8
8
ASMANEX HFA
4
6
VANCERIL DOUBLE STRENGTH AERS3,4
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. No PA for Pulmicort susp Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
if under 8 years old.
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. All preferreds must be
tried before moving to non
preferred steps.
3. All step 5 medications
need to be tried before
moving to step 8's.
4. Dosing limits apply to
whole category, please see
dosage consolidation list.
5. Asmanex 110mcg will be
limited to member between
the ages of 4-11years old.
6. Not approved for children
<12 years of age
Use PA Form# 20420
ANTIASTHMATIC - 5-Lipoxygenase
Inhibitors
MC
ZYFLO CR TABS
Use PA Form# 20420
Page 22 of 58
Other Preferred asthma controller drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists.
ANTIASTHMATIC - LEUKOTRIENE
RECEPTOR ANTAGONISTS
MC/DEL
MONTELUKAST SODIUM TAB
MC/DEL
7
MONTELUKAST GRANULE
MC/DEL
MONTELUKAST SODIUM CHEW TAB
MC/DEL
8
ACCOLATE TABS
MC/DEL
8
SINGULAIR
1
2
Use PA Form# 20420
1.Montelukast Granules will
only be approved if between
ages of 6months-24 months.
2.Singulair Chewables 4mg
from 2years-5years and
Singulair Chewables 5mgs
from 6years-14years old.
ANTIASTHMATIC - ALPHA-PROTEINASE
INHIBITOR
ANTIASTHMATIC - HYDRO-LYTIC
ENZYMES
ANTIASTHMATIC - MUCOLYTICS
MC
8
ARALAST
MC/DEL
8
ZEMAIRA
MC
8
GLASSIA
MC
8
PROLASTIN SUSR
MC/DEL
Use PA Form# 20420
PULMOZYME SOLN
Prolastin and Azemaira will be approved for members with A1AT deficiency and clinically demonstrable panacinar emphysema.
Will be approved for cystic fibrosis patients.
Use PA Form# 20420
MC/DEL
MC
MUCOMYST
MC
ORKAMBI
MC
KALYDECO
MC
ESBRIET1
ACETYLCYSTEINE1
1. Acetylcysteine is covered
with diagnosis of CF.
Use PA Form# 20420
ANTIASTHMATIC-CFTR POTENTIATOR
AND COMBINATIONS
Use PA Form# 20420
MC/DEL
IDIOPATHIC PULMONARY FIBROSIS
Kalydeco wil be considered for patients 6 years of age or older; and has a diagnosis of cystic fibrosis with a G551D mutation in the CFTR gene as detected by an FDA-cleared CF
mutation test; and prescriber is a CF specialist or pulminologist; and patient does not have one of the following infections: Burkholderia cenocepacia, dolosa or mycobacterium
abcessus
1. Diagnosis required
OFEV1
Ofev- Avoid concomitant use with P-gp and CYPA4 inducers (e.g. carbamazepine, phenytoin, and St. John’s wort
Esbriet- The concomitant use with strong CYP1A2 inhibitors (e.g. fluvoxamine, enoxacin) is not recommended
Use PA Form# 20420
COUGH/COLD
COUGH/COLD
MC/DEL
DEXTRO-GUAIF SYRP1
MC/DEL
MC/DEL
GUAIFENESIN SYRP1
1. All of cough cold
preparations are not
covered except these
preferred products.
PSEUDOEPHEDRINE1
MC
ROBITUSSIN DM SYRP1
MC
ROBITUSSIN SUGAR FREE SYRP1
All non-preferred products are not covered as permitted by Federal Medicaid regulations and MaineCare Policy.
Use PA Form# 20420
DIGESTIVE AIDS / ASSORTED GI
GI - ANTIPERISTALTIC AGENTS
GI - ANTI-DIARRHEAL/ ANTACID - MISC.
MC/DEL
DIPHENOXYLATE
MC/DEL
LOFENE TABS
MC/DEL
DIPHENOXYLATE/ATROPINE
MC
LONOX TABS
MC/DEL
LOPERAMIDE HCL CAPS/LIQ
MC
MOTOFEN TABS
MC/DEL
OPIUM TINCTURE TINC
MC
PAREGORIC TINC
MC
ATROPINE SULFATE SOLN
MC/DEL
BELLADONNA ALKALOIDS & OP
MC/DEL
BENTYL SYRP
MC/DEL
BENTYL TABS
MC/DEL
BISMATROL
MC
CUVPOSA
MC/DEL
BISMUTH SUBSALICYLATE
ED-SPAZ
MC/DEL
CALCIUM CARBONATE (ANTACID) CHEW
MC
MC
MC/DEL
DICYCLOMINE HCL
MC/DEL
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
Use PA Form# 20420
1.Dosing limits apply please on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
refer to Dose Consolidation preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
List
FULYZAQ1
GLYCOPYRROLATE INJ
Page 23 of 58
MC/DEL
MC
GLYCOPYRROLATE TABS
MC/DEL
HYOSCYAMINE SL
HAPONAL TABS
MC/DEL
LEVBID TB12
MC/DEL
HYOSCYAMINE CAPS & TABS
MC
LEVSIN ELIX
MC/DEL
HYOSCYAMINE SULFATE
MC
LEVSIN TABS
MC/DEL
KAOPECTATE
MC
LEVSIN/SL SUBL
MC/DEL
MAGNESIUM OXIDE TABS
MC
NULEV TBDP
MC/DEL
MAG-OX 400 TABS
MC
ROBINUL INJ
MC/DEL
PAMINE TABS
MC
ROBINUL TABS
MC/DEL
PROPANTHELINE BROMIDE TABS
MC/DEL
SAL-TROPINE TABS
MC/DEL
SODIUM BICARBONATE TABS
MC/DEL
TUMS
MC
CHOLBAM
GI- BILE ACID
GI - H2-ANTAGONISTS
MC/DEL
CIMETIDINE
MC
AXID CAPS
MC/DEL
FAMOTIDINE
MC
AXID AR TABS
MC/DEL
RANITIDINE 150MG TABS
MC/DEL
NIZATIDINE CAPS
MC/DEL
MC
RANITIDINE SYRP
MC/DEL
PEPCID
ACID REDUCER TABS
MC
MC/DEL
PEPCID AC
MC/DEL
ZANTAC SYRP
MC/DEL
OMEPRAZOLE 20MG2
MC/DEL
PANTOPRAZOLE
Fulyzaq requires a diagnosis of non-infectious diarrhea in patients with HIV/AIDS on anti-retroviral therapy, prior trials of preferred, more cost effective anti-diarrheals.
Indication of bile acid synthesis disorders due to single enzyme defects (SEDs) AND for adjunctive treatment of peroxisomal disorders (PDs)
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DDI: Ranitidine and cimetidine will now be non-preferred and require prior authorization if it is currently being used with any sulfonylurea (except for glyburide).
RANITIDINE 150MG CAPS
MC/DEL
GI - PROTON PUMP INHIBITOR
Preferred products that used to require diag codes still require diag codes unless indicated otherwise.
ZANTAC TABS
MC/DEL
6
NEXIUM CPDR4
MC
7
PRILOSEC OTC4
ACIPHEX TBEC4
DEXILANT (KAPIDEX)2
MC
7
MC/DEL
MC/DEL
8
MC/DEL
MC/DEL
DDI: Cimetidine will require prior authorization if being used in combination with Plavix.
1. Prevacid Solutabs
available without PA for
children less than 9 years
old.
All preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Patients obtaining refills as of 7/10/09 will begin to require prior authorizations if they have been on any PPI longer than 60 days in the past year.
The 12-month period is patient specific and begins 12 months before the requested date of prior authorization. Payment for usage beyond these limits will be authorized for cases in
which there is a diagnosis of:
8
PREVACID CPDR4,5
PREVACID SOLUTABS1
2. Dosing limits apply,
please see dosage
consolidation list.
8
8
PRILOSEC CPDR
PROTONIX INJ
3. Please use multiple 20mg 2. Erosive esophagitis
Capsules to obtain required 3. Hypersecretory conditions (Zollinger-Ellison syndrome, systemic mastocytosis, multiple endocrine adenomas). Recurrent peptic ulcer disease after documentation of previous trials
dose.
and therapy failure with at least one histamine H2-receptor antagonist at full therapeutic doses and with documentation of either failure of Helicobacter pylori treatment or anegative
Helicobacter pylori test result.
MC/DEL
8
PROTONIX2
MC/DEL
MC
8
8
OMEPRAZOLE 10MG2
OMEPRAZOLE-SODIUM BICARBONATE CAPS
MC/DEL
8
LANSOPRAZOLE
MC
9
OMEPRAZOLE 40MG3
8
MC/DEL
4. All preferreds and step
therapy must be tried and
failed.
1. Barrett’s esophagus.
4. Symptomatic gastroesophageal reflux after documentation of previous trials and therapy failure with at least onehistamine H2-receptor antagonist at full therapeutic doses. Patients
may be required to step down from a PPI to a histamine H2-receptor antagonist during the 12 months or on an annual clinical review if PPI therapy is continued.
DDI: Omeprazole will require prior authorization if being used in combination with Plavix.
DDI: Prevacid, Omeprazole and pantoprazole will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following
5. Established users prior to medications: Ampicillin, B-12, Fe salts, Griseofulvin, Sporanox, Ketoconazole, Reyataz, or Vantin.
10/1/09 may continue to
DDI: All non-preferred PPIs require prior authorization, but with any prior authorization request, the member's drug profile will also be monitored for current use with ampicillin, B-12, Fe
obtain Prevacid until
salts, griseofulvin, itraconazole, ketoconazole, Reyataz or Vantin due to a significant drug-drug interaction.
12/31/09.
Use PA Form# 20720
GI - ULCER ANTI-INFECTIVE
GI - PROSTAGLANDINS
MC
MC
HELIDAC
MC
PREVPAC
MC
PYLERA
MISOPROSTOL TABS
MC/DEL
CYTOTEC TABS
MC/DEL
CREON1
MC/DEL
LACTRASE CAPS
MC/DEL
MC/DEL
LACTASE CHEW
Use PA Form# 20420
Use PA Form# 20420
GI - DIGESTIVE ENZYMES
MC
MC
PANCREAZE
LACTASE TAB
MC/DEL
PERTZYE
ZENPEP1
MC/DEL
ULTRESA
MC/DEL
VIOKACE
Page
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drug will be approved, unless an acceptable clinical exception is offered on
the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Non -Preferred drugs must be tried and failed in step-order due to lack of efficacy or intolerable side effects before other non-preferred drugs will be approved, unless an acceptable
Use PA Form# 20420
1. Clinical PA is required to clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
establish CF diagnosis and between another drug and the preferred drug(s) exists.
medical necessity. In all
cases except cystic fibrosis
patients, objective evidence
24
of 58 insufficiency
of pancreatic
(fat malabsorption test etc...)
medical necessity. In all
cases except cystic fibrosis
patients, objective evidence
of pancreatic insufficiency
(fat malabsorption test etc...)
must be supplied.
GI - ANTI - FLATULENTS / GI
STIMULANTS
MC
CONSTULOSE SYRP
MC/DEL
ENULOSE SYRP
GASTROCROM CONC
MC
GI - INFLAMMATORY BOWEL AGENTS
CALULOSE SYRP
MC/DEL
1
MC/DEL
GENERLAC SYRP1
MC/DEL
MC/DEL
LACTULOSE SYRP1
METOCLOPRAMIDE HCL
MC/DEL
SIMETHICONE
MC/DEL
MC
AMITIZA2
CEPHULAC SYRP
MC/DEL
INFANTS GAS RELIEF SUSP
MC/DEL
REGLAN TABS
1. Diag codes no longer
necessary for preferred
products. Lactulose has
60cc/day QL
Use PA Form# 20420
2. Prior failed trials of
multiple other preferred GI
agents must occur first,
Such as OTC senna,
docusate, lactulose,
polyethylene glycol.
MC
APRISO
MC/DEL
ASACOL 800MG HD
MC
AZULFIDINE TABS
MC/DEL
AZULFIDINE EN-TABS TBEC
MC/DEL
BALSALAZIDE
MC/DEL
DELZICOL
MC
CANASA SUPP
GIAZO
MC
COLAZAL CAPS
MC
MC/DEL
MC
DIPENTUM CAPS
MC/DEL
MC
PENTASA CPCR 250MG
MC
PENTASA 500MG2
SFROWASA
MC/DEL
ROWASA ENEM
MC
UCERIS RECTAL FOAM3
MC/DEL
SULFAZINE EC TBEC
MC
UCERIS TABS3
3. Diagnosis required
MC/DEL
SULFASALAZINE TABS
LOTRONEX TABS
Use PA Form# 20420
GI - IRRITABLE BOWEL SYNDROME
AGENTS
MC/DEL
GI- SHORT BOWL SYNDROME
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
MC
Use PA Form# 20420
1. Current users
grandfathered.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
LIALDA TABS1
2. Use multiple Pentasa
250mg.
Giazo is only indicated for males, as the safety.efficacy for use in females has not been established.Prior trials of preferred products.
Uceris Rectal Foam or Tab- Concomitant use with CYP3A inhibitors (e.g. ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, erythromycin, cyclosporine, and grapefruit juice)
should be avoided. Verify prior trials and failures or intolerance of preferred treatments
Lotronex will be approved for females with IBS and predominant diarrhea. Prior failed trials of multiple preferred GI agents must occur first. IBS dx must be thoroughly documented.
Gattex requires a diagnosis of adult SBS who are dependent on parenteral support. Appropriate colonoscopy and lab assessments 6months prior to starting
GATTEX
MISCELLANEOUS GI
GI - MISC.
MC/DEL
BISAC-EVAC SUPP
MC/DEL
BISACODYL
MC/DEL
ACTIGALL CAPS
MC
BENEFIBER
MC
BISCOLAX SUPP
MC/DEL
CARAFATE
MC
CINOBAC CAPS
MC/DEL
CLEARLAX POW
MC/DEL
CITRATE OF MAGNESIA SOLN
MC/DEL
COLACE CAPS
MC/DEL
CITRUCEL
MC/DEL
COLYTE
MC/DEL
DIOCTO SYRP
MC
DIOCTO-C SYRP
DOCUSATE CALCIUM CAPS
MC
DOC SOD /CAS CAP
MC
DOC-Q-LAX CAPS
MC
MC/DEL
DOCUSATE SODIUM
MC/DEL
FIBER LAXATIVE TABS
MC/DEL
DOCUSATE SODIUM/CAS CAPS
FLEET
MC/DEL
DOK PLUS
MC/DEL
GENFIBER POWD
MC/DEL
DULCOLAX SUPP
MC/DEL
GLYCERIN
MC
FIBER CON TABS
MC/DEL
FIBER-LAX TABS
MC
GOLYTELY SOLR
MC
MC
MC/DEL
HIPREX TABS
KRISTALOSE PACK
MC
MAALOX
MC
METAMUCIL
MC/DEL
MC/DEL
MC
LINZESS
MALTSUPEX
MILK OF MAGNESIA SUSP
MC
MIRALAX PACK (OTC versions)
MC
MINERAL OIL OIL
MC
MIRALAX POWD (OTC versions)
MC
NULYTELY SOLR
MC/DEL
MC
MC/DEL
SENNA
MC/DEL
SENOKOT GRAN
MC
1. Must show evidence of
trials of preferred agents
that do not require PA, such
as OTC senna, docusate,
mineral oil and prescription
lactulose.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
Preferred products that used to require diag codes still require diag codes unless indicated otherwise.
2. Quantity Limit: 255 g/90day without PA for greater
Linzess is non-preferred and is for adults as treatment of IBS-Constipation AND treatment of chronic idiopathic constipation in adults. Prior trials of preferred agents for constipation
than 18 years old. If under
and IBS-constipation.
18 years of age, allowed
17gms daily without PA.
3.Multiple preferred agents
and dietary changes are
required.
Use PA Form# 20420
MOVANTIK3
PEG 3350 POWDER2
PEG-ELECTROLYTES SOLR
Page 25 of 58
MC/DEL
SENOKOT SYRP
MC/DEL
SENOKOT CHILDRENS SYRP
MC
MC/DEL
PREPOPIK PAK
SENEXON TABS
SENOKOT XTRA TABS
MC/DEL
SENOKOT TABS
MC
MC/DEL
STOOL SOFTENER CAPS
MC/DEL
SUCRALFATE TABS
MC
MC/DEL
SENOKOT S TABS
SORBITOL
MC
UNI-EASE CAPS
MC
MC
UNIFIBER POWD
MC/DEL
MC
URSO FORTE
MC
UNI-EASE PLUS CAPS
URSODIOL
MC
V-R NATURAL SENNA LAXATIV TABS
MC
URSO 250
MC/DEL
STOOL SOFTENER PLUS CAPS
UNI-CENNA TABS
MISC. UROLOGICAL
UROLOGICAL - MISC.
MC
MC
ACETIC ACID 0.25% SOLN
MC
CYTRA-K SOLN
MC/DEL
CYTRA-2 SOLN
MC
FURADANTIN SUSP
K-PHOS MF TABS
MC/DEL
MC/DEL
ELMIRON CAPS1
MACROBID CAPS
MC/DEL
METHENAMINE MANDELATE TABS
MC/DEL
MONUROL PACK
MC/DEL
MC/DEL
MACRODANTIN CAPS
NITROFURANTOIN MACR SUSP
MC/DEL
MC/DEL
NEOSPORIN GU IRRIGANT SOLN
MC/DEL
MC
MC
PYRIDIUM PLUS TABS
PHENAZOPYRIDINE HCL TABS
MC/DEL
PHENAZOPYRIDINE PLUS
MC/DEL
RENACIDIN SOLN
MC/DEL
PROSED/DS TABS
MC
MC
MC/DEL
MC
1. Elmiron requires
adequate proof of Dx with
supportive testing.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
POTASSIUM CITRATE/CITRIC SOLN
MC/DEL
MC
MC/DEL
NITROFURANTOIN MONO CAPS
CITRIC ACID/SODIUM CITRAT SOLN
PYRIDIUM TABS
TRICITRATES SYRP
URELIEF PLUS
UREX TABS
URISED TABS
UROCIT-K
MC/DEL
UROQID #2 TABS
MC/DEL
CALCIUM ACETATE TAB1
CALCIUM ACETATE CAP1
PHOSPHATE BINDERS
PHOSPHATE BINDERS
MC/DEL
MC/DEL
MC/DEL
ELIPHOS1
MC
MC/DEL
PHOSLYRA1
MC/DEL
CLEOCIN CREA
MC/DEL
METROGEL VAGINAL GEL2
MC/DEL
METRONIDAZOLE VAGINAL GEL2
MC/DEL
CLEOCIN SUPP1
MAGNEBIND - 400
MC
MC/DEL
MC/DEL
1
MC
1
AURYXIA
FOSRENOL1
Use PA Form# 20420
1. Diag required.
RENVELA1
VELPHORO1
RENAGEL1
INTRA-VAGINALS
VAGINAL - ANTIBACTERIALS
MC/DEL
MC/DEL
NUVESSA
VANDAZOLE
1. Step order must be
Preferred drugs must be tried and failed in step-order due to lack of efficacy or intolerable side effects before less preferred drugs will be approved, unless an acceptable clinical
followed to avoid PA. Must exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
fail Cleocin Cream and
another drug and the preferred drug(s) exists.
Metronidazole products
before moving to next step
product without PA.
2. Dosing limits apply,
please see Dosage
Consolidation List.
Use PA Form# 20420
VAGINAL - ANTI FUNGALS
MC
CLINDESSE CREA
MC
MC/DEL
CLOTRIMAZOLE CREA
MC
AVC CREA
CLOTRIMAZOLE 3 DAY CREA
MC/DEL
GYNE-LOTRIMIN CREA
MC
GYNAZOLE-1 CREA
MC
GYNE-LOTRIMIN 3 TABS
MC
MC/DEL
MICONAZOLE CREA
MC/DEL
MICONAZOLE 3 COMBO PACK KIT1
MICONAZOLE 7 CREA
MC/DEL
MICONAZOLE NITRATE CREA
MC
MC/DEL
MC/DEL
1. Quantity limit: 1/script/2
weeks
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MICONAZOLE 3 SUPP
MC
TERAZOL 3 CREA
MC
TERAZOL 7 CREA
NYSTATIN TABS
MC/DEL
TERCONAZOLE 0.8MG
TERCONAZOLE 0.4MG
MC/DEL
TERCONAZOLE SUPP
DDI: Miconazole will require prior authorization if being used in combination with Warfarin.
Page 26 of 58
MC
MC
VAGITROL
V-R MICONAZOLE-7 CREA
VAGINAL - CONTRACEPTIVES
Use PA Form# 20420
VAGINAL - ESTROGENS
MC/DEL
ESTRING RING
MC/DEL
ESTRACE CREA
MC/DEL
PREMARIN CREA
MC/DEL
VAGIFEM TABS
MC/DEL
ACID JELLY GEL
MC
1
1
1. Must fail all preferred
products before nonpreferred.
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drug will be approved, unless an acceptable clinical exception is offered on
the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
VAGINAL - OTHER
AMINO ACID CERVICAL CREA
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. There will be dosing
limits of 1 tab per day with
out PA.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists. Approval of a non-preferred 5-alpha reductase inhibitor requires objective clinical evidence of a very enlarged prostate rather than just the
presence of obstructive urinary outflow symptoms along with adequate trial of preferred Proscar.
MC
ACI-JEL GEL
MC
CERVICAL AMINO ACID CREA
MC/DEL
DOXAZOSIN MESYLATE TABS
MC/DEL
5
FLOMAX CP24
MC/DEL
MC/DEL
8
ALFUZOSIN
MC/DEL
FINASTERIDE1
TERAZOSIN HCL CAPS
MC/DEL
8
AVODART2,4
MC/DEL
TAMSULOSIN HCL
MC/DEL
8
CARDURA TABS4
MC/DEL
8
JALYN3,4
MC/DEL
8
PROSCAR TABS4
MC/DEL
8
RAPAFLO4
MC/DEL
8
UROXATRAL4
BPH
BPH
2. Prior use of preferred
agent prior to any approvals.
3. Use of preferred
(tamsulosin and finasteride)
and (tamsulosin and nonpreferred Avodart).
4. Non-preferred products
must be used in specified
order.
Use PA Form# 20420
ANXIOLYTICS
ANXIOLYTICS - BENZODIAZEPINES
ANXIOLYTICS - MISC.
MC/DEL
ALPRAZOLAM TABS
MC/DEL
8
ALPRAZOLAM ER
MC/DEL
CHLORDIAZEPOXIDE HCL CAPS
MC/DEL
8
ATIVAN
MC/DEL
CLORAZEPATE DIPOTASSIUM TABS
MC/DEL
8
NIRAVAM
MC/DEL
DIAZEPAM
MC/DEL
8
SERAX
MC/DEL
LORAZEPAM
MC/DEL
8
TRANXENE
MC/DEL
OXAZEPAM CAPS
MC/DEL
8
XANAX TABS
MC/DEL
9
XANAX XR
MC/DEL
BUSPIRONE HCL TABS
MC
BUSPAR TABS
MC
HYDROXYZINE HCL SOLN
MC
DROPERIDOL SOLN
MC
HYDROXYZINE HCL SYRP
MC/DEL
HYDROXYZINE HCL TABS
MC/DEL
HYDROXYZINE PAMOATE CAPS
HYDROXYZINE PAMOATE 100MG CAPS
MC/DEL
MEPROBAMATE TABS
MC/DEL
MC/DEL
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
VISTARIL
ANTI-DEPRESSANTS
ANTIDEPRESSANTS - MAO INHIBITORS
MC/DEL
NARDIL TABS
MC/DEL
PARNATE TABS
ANTIDEPRESSANTS - MAO INHIBITORS
TOPICAL
MC/DEL
TRANYLCYPROMIINE
Use PA Form# 20420
MC/DEL
EMSAM1
1. Dosing limits apply,
please refer to Dose
consolidation list.
Preferred drugs (including a preferred SSRI, a non-SSRI, and Venlafaxine ER ) must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will
be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
significant potential drug interaction between another drug and the preferred drug(s) exists.
Use PA Form# 20420
ANTIDEPRESSANTS - SELECTED SSRI's
MC/DEL
BUPROPION HCL TABS
MC/DEL
8
MC/DEL
BUPROPION SR
MC/DEL
BUPROPION XL
MC/DEL
MC/DEL
8
8
MC/DEL
CITALOPRAM4
DULOXETINE
ESCITALOPRAM4
MC
8
MC/DEL
8
CYMBALTA5
EFFEXOR TABS
MC/DEL
8
EFFEXOR XR CP24 3, 10
FLUOXETINE HCL CAPS
MC/DEL
8
FETZIMA12
MC/DEL
MC/DEL
MC/DEL
APLENZIN7
BRINTELLIX13
CELEXA4
1. Use Fluoxetine 20 mg in Preferred drugs (including failure of at least one preferred SSRI, one SNRI and one non-SSRI/SNRI) must be tried for at least 4 weeks each and failed due to lack of efficacy or
multiples.
intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a
condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the preferred drug(s) exists.
2. See Zoloft splitting table.
Sertraline requires splitting
of scored tabs to avoid PA.
Page 27 of 58
Criteria for new starters <18 years of age: Must have had fluoxetine trial for at least 30 days before accessing other preferred antidepressants without PA.
of scored tabs to avoid PA.
MC/DEL
FLUOXETINE HCL LIQD
MC/DEL
8
FLUOXETINE 40mg AND 60 mg CAPS
MC/DEL
FLUVOXAMINE MALEATE TABS
MC/DEL
8
6
MC/DEL
MIRTAZAPINE
MC
8
MC/DEL
NEFAZODONE
MC/DEL
8
MC/DEL
PAROXETINE
3
8
MC/DEL
SERTRALINE HCL2
TRAZODONE HCL TABS
MC/DEL
MC/DEL
MC
8
LEXAPRO TABS4
LUVOX TABS
MC/DEL
MC/DEL
VENLAFAXINE ER CAPS
9
8
FLUOXETINE 10mg AND 20mg TABS
FORFIVO XL
CYMBALTA: Fibromyalgia diagnosis- prior use and failure of preferred generics (amitriptyline or cyclobenzaprine) and gabapentin prior to approval.
Preferred Fluoxetine
will be
the onlyand
preferred
for members
who cyclobenzaprine
are less than 18 and
yearsgabapentin
of age. prior to approval.
SAVELLA:
Fibromyalgia
diagnosis
trial of antidepressant
a preferred generic
amitriptyline,
Exceptions to the rule are as follows:
1
IRENKA
14
KHEDEZLA
MC
8
MAPROTILINE HCL TABS
MC/DEL
8
MIRTAZAPINE ODT
MC
8
MC/DEL
8
OLEPTRO
PAROXETINE CR3
MC/DEL
8
PAXIL3
MC/DEL
8
MC/DEL
8
PAXIL CR
PRISTIQ
MC
8
PROZAC
MC
8
PROZAC CAPS
3
3. Strong caution with
pediatric population.
1. If the member (<18) is already an established user for any of the preferred or non-preferred drugs under the Antidepressant category on the PDL, then they can continue to get that
drug.
4. See Celexa/Citalopram 2. If the member (<18) has a prescription for an antidepressant that is on the PREFERRED side of the PDL and has had a 30 day supply of Fluoxetine at least 30 days before the date
and Lexapro splitting tables. they are getting it filled, the claim will pay. If they do not have the trial of Fluoxetine in their profile, the claim will reject for PA required.
3. If the member (<18) has a prescription for a medication that is on the NON-PREFERRED side of the PDL regardless of having Fluoxetine in their profile, the prescription will need a
PA.
5. Max daily dose allowed is 4. Use of a preferred antidepressant for anxiety will require the diagnosis of anxiety on written prescription and submitted during claim submission.
60mg, only 1 capsule per
day allowed for all strengths.
DDI: Fluvoxamine will now be non-preferred and require prior authorization if it is currently being used with glimepiride (Amaryl).
Combination of multiple
strengths require PA.
DDI: Preferred nefazodone will now be non-preferred and require prior authorization if it is currently being used in combination with either Onglyza 5mg, Enablex 15mg or Vesicare
10mg.
6. Use Fluoxetine 10mg tabs DDI: Fluoxetine will require prior authorization if being used in combination with Plavix.
in multiples.
DDI: Fluvoxamine will require prior authorization if being used in combination with Plavix.
MC
8
PROZAC WEEKLY CPDR
MC/DEL
8
REMERON TABS
MC/DEL
8
SARAFEM CAPS
MC/DEL
8
TRAZODONE HCL 300MG TABS
MC/DEL
8
WELLBUTRIN TABS
MC/DEL
8
MC/DEL
8
WELLBUTRIN SR TBCR
WELLBUTRIN XL
MC/DEL
MC/DEL
8
REMERON SOLTAB TBDP
8
MC/DEL
8
SAVELLA 8
ZOLOFT
8. Dosing limits allowing 2
tabs/day and a max daily
limit of 200mg / day applies.
Please see dose
consolidation list.
MC/DEL
8
VENLAFAXINE TABS9
9. Dosing limits and max
daily dose applies. Limit of
1 per day of 37.5mg, 75mg,
will be allowed without pa,
along with limits of 2 caps
per day of the 150mg
strength. Max daily dose
allowed is 375mg.
MC/DEL
8
VENLAFAXINE ER TABS9
10. Use venlafaxine ER
tabs.
MC/DEL
9
VIIBRYD
MC/DEL
9
FLUOXETINE 90mg TABS11
11. Non-preferred products SAVELLA: Fibromyalgia diagnosis and trial of a preferred generic amitriptyline, cyclobenzaprine, duloxetine and gabapentin prior to approval.
must be used in specified
step order.
7. Provide clinical
documentation as to why a
preferred generic alternative
cannot be used.
12. Requires previous
trials/failure of multiple
preferred medications.
Dosing limits apply,
please see the dose
consolidation list. Max
daily dose of 80mg if
used concomitantly with
strong CYP3A4 inhibitor.
13.Dosing limits apply,
please see dose
consolidation list.
Page 28 of 58
Use PA Form# 20420
ANTIDEPRESSANTS CYCLICS
TRI-
MC/DEL
AMITRIPTYLINE HCL TABS
MC/DEL
ANAFRANIL CAPS
MC/DEL
DESIPRAMINE HCL TABS
MC/DEL
DOXEPIN HCL1
MC/DEL
IMIPRAMINE HCL TABS1
MC/DEL
NORTRIPTYLINE HCL1
MC
PROTRIPTYLINE HCL TABS1
MC
SURMONTIL CAPS1
MC
BUTISOL SODIUM TABS1
1
1
1
MC/DEL
AMOXAPINE TABS
MC/DEL
CLOMIPRAMINE HCL CAPS
MC/DEL
DOXEPIN HCL 150 MG
MC/DEL
NORPRAMIN TABS
MC/DEL
PAMELOR
MC
TOFRANIL
MC
VIVACTIL TABS
2
1. Users over the age of 65 Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
require a pa.
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Use multiples of 50mg.
Use PA Form# 20420
Use PA Form# 10220 for
Brand Name requests
SEDATIVE / HYPNOTICS
SEDATIVE/HYPNOTICS - BARBITURATE
MC/DEL
CHLORAL HYDRATE SYRP1
MC
LUMINAL SOLN
MC/DEL
SOMNOTE CAPS
1. PA required for new users Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
of preferred products if over on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
65 years.
preferred drug(s) exists.
MC
MEBARAL TABS1
MC/DEL
PHENOBARBITAL1
MC/DEL
DORAL TABS1
MC
MC/DEL
ESTAZOLAM TABS1
MC
MC/DEL
FLURAZEPAM HCL CAPS1
MC/DEL
RESTORIL CAPS1
MC/DEL
TEMAZEPAM CAPS 15 & 30MG1
MC/DEL
TEMAZEPAM 7.5MG1
Use PA Form# 30110
AMBIEN1
ESZOPICLONE
1. Quantity Limt of 12 per 34 Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
days.
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Quantity limits will be
allowed up to 30/30, but
intermittent therapy is
Ambien, Ambien CR, Lunesta, Sonata, Zaleplon and Zolpidem may cause dependence with continued use and as with benzodiazepines, usage should be limited to 7-10 days at a
recommended.
time. Chronic intermittent use (2-3 days per week max) is the standard of care. Please refer to Sedative/Hypnotic PA form.
Use PA Form# 20420
SEDATIVE/HYPNOTICS BENZODIAZEPINES
MC/DEL
SEDATIVE/HYPNOTICS - NonBenzodiazepines
HALCION TABS1
MIDAZOLAM HCL SYRP
1. Dosing limits apply,
please see dosing
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Benzodiazepines do cause dependence with continued use and usage should be limited to 7-10 days at a time. Chronic intermittent use (2-3 Days per week
max) is the standard of care
1
MC/DEL
1
TRIAZOLAM TABS
MIRTAZAPINE
MC
1
TRAZODONE
MC/DEL
1
ZOLPIDEM 2
MC/DEL
2
ZALEPLON 2,3
MC/DEL
7
MC/DEL
7
MC/DEL
MC/DEL
7
8
ZOLPIDEM ER
MC/DEL
MCDEL
8
8
BELSOMRA1
AMBIEN CR1
EDLUAR
3. Only zolpidem trial/failure
will be required to obtain
DDI: Belsomra® with strong CYP3A inhibitors (e.g. ketoconazole, itraconazole, posaconazole, clarithromycin, nefazodone, ritonavir, saquinavir, nelfinavir, indinavir, boceprevir,
Zaleplon.
telaprevir, telithromycin, and conivaptan) is not recommended
MC
8
HETLIOZ
MC/DEL
MC/DEL
8
8
INTERMEZZO
MC/DEL
8
SONATA CAPS1
4. Must fail all preferred
products before nonpreferred
MC/DEL
8
ROZEREM
Use PA Form# 30110
MC/DEL
8
ZOLPIMIST
MC/DEL
8
ABILIFY DISC TAB, INJ and SOL2
MC/DEL
8
MC
MC
8
8
ABILIFY MAINTENA
ARISTADA7
MC/DEL
8
GEODON
MC
8
INVEGA
MC
8
INVEGA SUSTENNA
MC/DEL
MC
8
8
INVEGA TRINZ INJ
LATUDA
MC
MC
8
8
REXULTI
RISPERDAL TAB
MC
8
RISPERDAL CONSA 2
Atypicals: Prior Authorization will be required for preferred medication to assure indication is in accordance with FDA approved or literature supported evidence-based best practices.
The approved indications are:
MC
8
8
RISPERDAL M TAB2
RISPERDAL SOLN
• schizophrenia
MC
MC/DEL
8
RISPERIDONE ODT
LUNESTA1
ANTI-PSYCHOTICS
ANTIPSYCHOTICS - ATYPICALS
MC
MC/DEL
MC/DEL
MC/DEL
ABILIFY TABS3,4
4
OLANZAPINE
RISPERIDONE TAB4
MC/DEL
RISPERIDONE SOLN4
QUETIAPINE4,6
MC/DEL
ZIPRASIDONE4
FANAPT
If prescribing 2 or more
antipsychotics, PA will be
required for both drugs,
except if one is
Clozapine.This also includes
combination of Seroquel
with Seroquel XR.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Non preferred atypicals will be approved for patients with FDA-approved indications, and for specific conditions supported by at least two published peerreviewed double-blinded, placebo-controlled randomized trials that are not contradicted by other studies of similar quality and as long as all first line preferred therapies have been tried
and failed at full therapeutic doses for adequate durations (at least two weeks). * Abilify: doses above 15mg were not shown to be more effective than doses in the 10-15mg range.
Prescriptions for quetiapine are limited to a maximum daily dose of 800mg.
Use PA form# 20440 for
Multiple Antipsychotic
requests
DDI: Abilify, Latuda, Quetiapine, and Zyprexa will now be non-preferred and require prior authorization if they are currently being used in combination with carbamazepine.
Please use Drug-Drug Interaction PA form #10400.
• bipolar disorder
Use PA form# 10130 for non- • agitation related to autism
preferred single therapy
atypical requests
Page 29 of 58
MC/DEL
8
SAPHRIS
MC/DEL
8
SEROQUEL 50MG TABS
MC
8
ZYPREXA TABS
MC
8
MC
8
ZYPREXA ZYDIS TBDP
ZYPREXA RELPREVV
MC/DEL
MC/DEL
8
9
1. Please use multiple
25mg tablets.
If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine.This also includes combination of Seroquel with Seroquel XR.
1,2
SEROQUEL TABS
SEROQUEL XR5
2
• severe behavioral dyscontrol with risk of imminent need for emergency services such as the emergency room, crisis services, or an inpatient psychiatric facility.
2. Established users of
single therapy atypicals
Aristada- establish tolerability to Abilify/oral aripiprazole
were grandfathered.
3. Abilify requires splitting of
tab to avoid PA. Please see
Abilify splitting table.
4. Prior Authorization will be
required for preferred
medications for members
under the age of 5.
5. Product is considered line
extension of the original
product due to Healthcare
Reform (HCR). MaineCare
will consider these
medications non-preferred
and a step 9 because of the
impact under the Federal
Rebate Program in
conjunction with HCR.
6. Dosing limits apply:
quetiapine 25mg, 50mg and
100mg are available without
PA if the daily dosage is less
than 1.5 tablets
7. Clinical PA required
establishing significant
reason why an oral agent
can’t be used
ANTIPSYCHOTICS - SPECIAL
ATYPICALS
MC/DEL
MC/DEL
CLOZAPINE TABS
MC
CLOZARIL TABS
Use PA Form# 20420
FAZACLO
Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred brand will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists. Patients previously stabilized on brand name drug will be approved.
DDI: Clozapine will now be non-preferred and require prior authorization if it is currently being used in combination with carbamazepine.
Please use Drug-Drug Interaction PA form #10400.
ANTIPSYCHOTICS - TYPICAL
MC/DEL
CHLORPROMAZINE HCL
MC/DEL
COMPAZINE
MC/DEL
FLUPHENAZINE DECANOATE
MC/DEL
COMPRO SUPP
MC/DEL
FLUPHENAZINE HCL
MC
MC/DEL
MC
MC/DEL
HALDOL
MC
HALOPERIDOL
MC
HALOPERIDOL DECANOATE SOLN
MC
MC/DEL
HALDOL DECANOATE
LOXITANE CAPS
MELLARIL
NAVANE CAPS
HALOPERIDOL LACTATE SOLN
MC
PROLIXIN
MC/DEL
LOXAPINE SUCCINATE CAPS
MC
STELAZINE TABS
MC/DEL
LOXITANE-C CONC
MC
MOBAN TABS
MC/DEL
PERPHENAZINE
MC/DEL
PROCHLORPERAZINE
MC
Use PA Form# 20420
If prescribing 2 or more
antipsychotics, PA will be
required for both drugs,
except if one is Clozapine.
SERENTIL
MC/DEL
THIORIDAZINE HCL
MC/DEL
THIOTHIXENE
MC/DEL
TRIFLUOPERAZINE HCL TABS
MC/DEL
LITHIUM CARBONATE
MC/DEL
ESKALITH CAPS
MC/DEL
LITHIUM CITRATE SYRP
MC/DEL
ESKALITH CR TBCR
LITHIUM
LITHIUM
Use PA Form# 20420
Page 30 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
If prescribing 2 or more antipsychotics, PA will be required for both drugs, except if one is Clozapine.
COMBINATION - PSYCHOTHERAPEUTIC
PSYCHOTHERPEUTIC COMBINATION
MC/DEL
CHLORDIAZEPOXIDE/AMITRIPT
MC/DEL
PERPHENAZINE/AMITRIPTYLIN
MC
8
1
SYMBYAX
1. Only available if
component
ingredients are unavailable.
Use PA Form# 20420
STIMULANTS
STIMULANT - AMPHETAMINES -SHORT
ACTING
MC/DEL
AMPHETAMINE SALT COMBO1,4
MC/DEL
MC/DEL
DEXTROAMPHET SULF TABS1,3
MC
ADDERALL TABS
EVEKEO
MC/DEL
DEXEDRINE1,3,4
MC
PROCENTRA
1. Preferred stimulants will
be available without PA if
diagnosis of ADHD.
2. As per recent FDA alert,
Adderal & Dexedrinel should
not be used in patients with
underlying heart defects
since they may be at
increased risk for sudden
death.
3. Dosing limits apply,
please see dosing
consolidation list.
4. Max daily dose of 50mg.
Use PA Form# 20420
STIMULANT - LONG ACTING
AMPHETAMINES SALT
MC
VYVANSE2,3,4
MC
8
ADDERALL XR CP241,3,4
MC/DEL
9
AMPHETAMINE/DEXTROAMPHET ER
Use PA Form# 20420
Adderall XR- Current users as of 12/31/11 without prior use of Vyvanse will be required to transition to the preferred vyvanse product. Other members
1. As per recent FDA alert, will required PA
Adderall should not be used
in patients with underlying
heart defects since they may
be at increased risk for
sudden death.
Quillivant is only indicated for use in patients 6 years of age and older. Prior trials of preferred products
2. FDA approval is currently
for adults and children 6 or
older. Will be available
without PA for this age
group if within dosing limits.
Limit of one capsule daily.
Max dose of 70MG daily.
3. Preferred stimulants will
be available without PA if
diagnosis of ADHD.
4. Dosing limits applly,
please see dosing
consolidation list.
LONG ACTING AMPHETAMINES
MC
DEXEDRINE CAP CR1,2,3
MC
DEXTROAMPHET SULF CPCR3
1. Preferred stimulants will
be available without PA if
diagnosis of ADHD.
2. As per recent FDA alert,
Adderall & Dexedrine should
not be used in patients with
underlying heart defects
since they may be at
increased risk for sudden
death.
Page 31 of 58
3. Dosing limits applly,
please see dosing
consolidation list.
Use PA Form# 20420
STIMULANT - METHYLPHENIDATE
STIMULANT - METHYLPHENIDATE LONG ACTING
1
MC/DEL
MC/DEL
DEXMETHYLPHENIDATE IR TABS
FOCALIN IR TABS
MC/DEL
MC/DEL
METADATE ER TBCR1,2
MC
METHYLIN ER TBCR1,2
MC/DEL
MC/DEL
METHYLIN TABS1,2
MC/DEL
METHYLIN SOL1
MC/DEL
METHYLPHENIDATE HCL1,2
MC/DEL
DAYTRANA
1,3
MC
5
METADATE CD CPCR
MC/DEL
FOCALIN XR1
METHYLPHENIDATE ER TABS
RITALIN LA4
8
8
APTENSIO
MC/DEL
MC/DEL
MC
MC
MC/DEL
8
CONCERTA TBCR2
METHYLPHENIDATE ER CAPS1,2,4
MC
8
QUILLIVANT XR
METHYLIN CHEWABLES
RITALIN
1. Preferred stimulants will
be available without PA if
diagnosis of ADHD.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Please refer to General Criteria category E.
Use PA Form# 20420
2. Dosing limits apply,
please see dosing
consolidation list. Maximum
daily doses are as follows:
72mg daily for
methylphenidate and 36mg
daily for
dexmethylphenidate.
1. Preferred stimulants will
be available without PA if
diagnosis of ADHD.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Non-preferred products
must be used in specified
step order.
3.FDA approval currently
only for ages 6-16. Limit of
one patch daily. Max dose
of 30MG daily.
4.Dosing limits applly,
please see dosing
consolidation list.
Use PA Form# 20420
STIMULANT - STIMULANT LIKE
MC/DEL
MC
GUANFACINE ER
KAPVAY
MC/DEL
MC
7
7
3
PROVIGIL TABS
STRATTERA1, 2
MC
8
MC/DEL
8
MC/DEL
8
9
MODAFINIL TABS
9
DESOXYN TABS3
9
DESOXYN CR3
MC/DEL
MC
MC
CAFCIT SOLN3
INTUNIV
NUVIGIL3
1. Failure of both an
Provigil requests require diagnosis of Narcolepsy, ADHD, or Obstructive Sleep Apnea. Previous failures of methylphenidate and amphetamine is required for Narcolepsy and ADHD
amphetamine and
diagnosis, with additional Strattera trial needed with ADHD diagnosis. Please refer to detailed criteria on Provigil PA form
methylphenidate is required
for consideration for
approval of Strattera, unless
history of substance abuse
without current use of
abusable medication(s).
Additionally, for patients <17
years of age, a trial of
quanfacine in required
before approval of Strattera.
2. Strattera currently has
dosing limitations allowing
one tablet per day for all
strengths if obtain approval.
Max daily dose of Strattera
is 100mg. Please see
dosing consolidation list.
3. Non-preferred products
must be used in specified
step
order.use generic
4.
Please
Guanfacine.
Page 32 of 58
Use PA Form# 20710 for
Provigil, Nuvigil and Xyrem
Use PA Form# 20420 for all
others
ANTI-CATAPLECTIC AGENTS
PSYCHOTHERAPEUTIC AGENTS - MISC.
MC
NUEDEXTA
MC
XYREM SOL1
XENAZINE
MC
Use PA Form# 20710 for
Xyrem
FDA reminded healthcare professionals and patients that the combined use of Xyrem (sodium oxybate) with alcohol or central nervous system (CNS) depressant drugs can markedly
impair consciousness and may lead to severe breathing problems (respiratory depression
Use PA Form# 20710 for
Xenazine
1.See criteria section
WEIGHT LOSS
WEIGHT LOSS
No longer covered:
PHENTERMINE,
XENICAL,DIDREX, and
MERIDIA
Weight loss drugs are not covered as permitted by Federal Medicaid regulations and Maine Medicaid (MaineCare) Policy.
1. PA is required to
establish dementia
diagnosis and baseline
mental status score.
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
ALZHEIMER DISEASE
ALZHEIMER - Cholinomimetics/Others
MC/DEL
DONEPEZIL HYDROCHLORIDE TABS
MC/DEL
DONEPEZIL HYDROCHLORIDE ODT
1
MC/DEL
MC/DEL
1
MC
6
ARICEPT TABS2
MC
6
ARICEPT ODT2
EXELON DIS1
MC/DEL
7
DONEPEZIL HYDROCHLORIDE TABS 23MG
GALANTAMINE CAPS1
MC/DEL
8
EXELON CAP
MC/DEL
MC/DEL
GALANTAMINE TAB1
MC/DEL
MC
8
NAMZARIC
RAZADYNE2
MC/DEL
NAMENDA XR CAPS
8
9
2. Must fail all preferred
products before moving to
non-preferred.
COGNEX CAPS2
Use PA Form# 20420
MC/DEL
RIVASTIGMINE TARTRATE CAPS1
MC/DEL
CHANTIX TAB1,2
NICODERM CQ PT241
MC/DEL
NICOTINE DIS PT241
Use PA Form# 20420
1. See criteria section for
exemptions
NAMENDA1
1
MC
SMOKING CESSATION
NICOTINE PATCHES / TABLETS
MC/DEL
2. The Starter/Titration
packs are non-preferred.
Please use the tablets.
As of July 1, 2014 per MaineCare policy, smoking cessation products will be covered without a copay(including MEDEL). No annual or lifetime limits, must follow FDA approved
indications and therapy guidelines.
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Note: MaineCare policy, smoking cessation product were “not covered” except for during pregnancy between 9/1/12 and 1/1/14, between 1/1/2014 and 7/1/14 smoking cessation
products were covered with limitations
Patients may qualify for the medication through The Maine Tobacco Helpline. Patients are encouraged to call The Maine Tobacco helpline at 1-800-207-1230.
hemocyte
NICOTINE REPLACEMENT - OTHER
MC/DEL
NICOTINE POLACRILEX GUM1
MC/DEL
8
NICOTROL INHALER1,2
MC/DEL
8
NICOTROL NASAL SPRAY1,2
MC/DEL
8
MC
8
NICORETTE GUM1,2
NICORETTE LOZENGES
Use PA Form# 20420
1. See criteria section for
exemptions
As of July 1, 2014 per MaineCare policy, smoking cessation products will be covered without a copay(including MEDEL). No annual or lifetime limits, must follow FDA approved
indications and therapy guidelines.
2. Must use non-preferred
products in specified step
order.
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs (in step-order) will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists.
Note: MaineCare policy, smoking cessation product were “not covered” except for during pregnancy between 9/1/12 and 1/1/14, between 1/1/2014 and 7/1/14 smoking cessation
products were covered with limitations
Patients may qualify for the medication through The Maine Tobacco Helpline. Patients are encouraged to call The Maine Tobacco helpline at 1-800-207-1230.
ALCOHOL DETERRENTS
ALCOHOL DETERRENTS
MC
ANTABUSE TABS
MC
DISULFIRAM TABS
MC/DEL
ACAMPRO1
Page
1. Should only be used in
conjunction with formal
structured outpatient
detoxification
33
of 58 program.
Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists.
MC/DEL
1. Should only be used in
conjunction with formal
structured outpatient
detoxification program.
NALTREXONE HCL TABS
Preferred generic drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists.
Use PA Form# 20420
MISCELLANEOUS ANALGESICS
ANALGESICS - MISC.
MC
MC/DEL
ACETAMINOPHEN
MC/DEL
ASPIRIN
MC/DEL
ESGIC-PLUS
MC/DEL
ASPRIN/ APAP/ CAFF TAB
MC/DEL
FIORICET TABS
MC/DEL
BUTAL/ASA/CAFF
MC
FIORINAL CAPS
MC/DEL
BUTALBITAL COMPOUND
MC
FIORTAL CAPS
MC/DEL
BUTALBITAL/ACET TABS
MC/DEL
FORTABS TABS
MC/DEL
BUTALBITAL/APAP CAPS
MC
PHRENILIN TABS
MC/DEL
BUTALBITAL/APAP/CAFFEINE
MC
PHRENILIN FORTE CAPS
MC/DEL
CHOLINE MAGNESIUM TRISALI
MC
TRILISATE LIQD
MC/DEL
DIFLUNISAL TABS
MC
TRILISATE TABS
EXCEDRIN
MC
ZEBUTAL CAPS
SALSALATE TABS
MC
ZORPRIN TBCR
MC
MC/DEL
AXOCET CAPS
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
LONG ACTING NARCOTICS
NARCOTICS - LONG ACTING
MC/DEL
EMBEDA
MC
8
AVINZA
MC/DEL
MC
MC
8
BELBUCA
MC
MC/DEL
FENTANYL PATCH4
KADIAN
METHADONE
8
MC
8
DURAGESIC PT72
EXALGO
MC/DEL
METHADOSE
MC/DEL
MORPHINE SULFATE ER TB12
MC/DEL
MC/DEL
8
8
HYSINGLA ER
MORPHINE SULFATE SUPP
MC/DEL
BUTRANS4
MC/DEL
MC
8
MS CONTIN TB12
8
OPANA ER
MC/DEL
8
ORAMORPH SR TB12
MC/DEL
8
OXYCONTIN TB121
MC
8
XARTEMIS ER
MC
MC/DEL
8
9
ZOHYDRO ER
NUCYNTA ER
MC/DEL
9
OXYCODONE ER3,5
4
Preferred drugs (Fentanyl Patch, Morphine Sulfate ER tab, Kadian Methadone or Methadose) must be tried for at least 2 weeks each & failed due to lack of efficacy or intolerable side
effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents
usage of the preferred drug or a significant potential drug interaction between another drug & the preferred drug(s) exists. Adequate trials include prevention/treatment of common
adverse effects associated w/ narcotics (antinausea, antipruritics, etc.) as well as adequate equianalgesic dosing when converting from one narcotic to another.Also, adequate
1. Oxycontin will be
documentation of attempts to titrate dose of preferred agents to achieve adequate pain relief & desired clinical response must be provided. Member’s drug regimen for additions &/or
available without PA for
discontinuations of medications that may affect absorption &/or metabolism of preferred agents must be monitored. Approvals will not be granted if patient had access to either nonpatients treated for or dying
preferred products or high doses of short acting narcotics during the trial period. Non-preferred drugs will not be approved for patients showing evidence of usage patterns consistent w/
from cancer or hospice
controlled substance abuse such as:
patients. CA (cancer) or HO
(hospice) diag code may be
used but store must verify
since all scripts will be
audited and stores will be
1.Frequent or persistent early refills of controlled drugs;
liable.
2.Multiple instances of early refill overrides due to reports of misplacement, stolen, dropped in toilet or sink, distant travel, etc.;
Use PA Form# 20510
Use PA form #10300 for
PAs over the opiate limit
3.Breaches of narcotic contracts with any provider;
2. Established users are
grandfathered.
4.Failure to comply with patient responsibilities in attached opioid documentation (see PA form) including but not limited to failing to submit to and pass pill counts;
5.Failing to take or pass random drug testing;
3. Oxycodone ER allowed
only 2 per day for all
strengths except 80 mg,
where 4 are allowed to
4. Dosing limits apply.
Please see dose
consolidation list.
6.Failing to provide old records regarding prior use of narcotics;
5. Non-preferred products
must be used in specific
order.
9.Circumventing MaineCare prior authorization requirements for narcotics by paying cash for affected narcotics (prescribers failed to submit prior authorization prior to cash narcotic
scripts being filled by member).
7.Receiving controlled substances from other prescribers that the provider submitting the PA is unaware of
8.Documented history of substance abuse. Substance abuse evaluations may be required for patients with medical records displaying documented substance abuse or potential signs
of narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy" to all products but
Oxycontin.
10.Requests for any Brand name controlled substance, considered by authorities to be highly abused and diverted (Oxycontin, Percocet, Typox, Vicodin, Dilaudid, Ultracet...) with an
available AB rated generic equivalent will be denied unless it will be provided in a setting that virtually eliminates the risk of diversion.
11.Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the risk of cross-hypersensitivity.
Hysingla ER- Concomitant use should be avoided with mixed agonist/antagonist analgesics, partial agonist analgesics, and MAOIs. Verify prior trials and failures or intolerance of
preferred treatments
NARCOTICS - SELECTED
MC/DEL
TRAMADOL HCL TABS
MC/DEL
7
RYZOLT
MC
8
BUPRENEX SOLN
MC/DEL
8
BUTORPHANOL
MC
8
NALBUPHINE HCL SOLN
Use PA Form# 20420
Use PA form #10300 for
PAs over the opiate limit
1. Only available if
component
Page 34
of 58ingredients are
unavailable.
Preferred drugs from this and other narcotic classes must be tried for at least 2 weeks each and failed due to lack of efficacy or intolerable side effects before non-preferred drugs from
this class will be approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred
drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Approvals will not be granted if patient had access to either non-preferred
products or high doses of short acting narcotics during the trial period. Substance abuse evaluations may be required for patients with medical records displaying potential signs of
narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy" to all products but
desired product. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the risk of crosshypersensitivity.
MC
8
STADOL NS SOLN
MC
MC
8
TRAMADOL ER
8
MC
8
ULTRACET TABS
ULTRAM TABS
MC
9
ULTRAM ER
1. Only available if
component ingredients are
unavailable.
drug or a significant potential drug interaction between another drug and the preferred drug(s) exists. Approvals will not be granted if patient had access to either non-preferred
products or high doses of short acting narcotics during the trial period. Substance abuse evaluations may be required for patients with medical records displaying potential signs of
narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and intolerance or "allergy" to all products but
desired product. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class due to the risk of crosshypersensitivity.
1
Non-preferred drugs will not be approved for patients showing evidence of usage patterns consistent with controlled substance abouse such as:
1.frequent or persistant early refills of controlled drugs;
2.multiple instances of early refill overrides due to reports of misplacement, stolen, dropped in toilet or sink, distant travel;
3.breaches of narcotic contracts with any provider;
4.failure to comply with patient responsibilities in attached opiod documentaion (see PA form) including but not limited to failing to submit to and pass pill counts;
5.failing to take or pass random drug testing;
6.failing to provide old recoreds regarding prior use of narcotics;
7.receiving controlled substances from other prescribers that the provider submitting the PA is unaware of. in Substance abuse evaluations may be required for patients with medical
records displaying potential signs of narcotic misuse and abuse such as chronic early refills, short dosing intervals, frequent dose increases, multiple lost/stolen etc scripts and
intolerance or "allergy" to all products but Oxycontin. Allergic reactions to any product within a specific narcotic class will justify and preclude use of any other product in the same class
due to the risk of cross-hypersensitivity.
Effective 1/01/2013, MaineCare will implement a 15 day limit for members prescribed opiates for their treatment of pain.
1. MaineCare members will be allowed over a rolling 12 month period up to a 15 day supply of an opiate without prior authorization
2. Members requiring longer than 15 days will require a PA for continuation of therapy and providers may provide medical necessity
3. Members may be eligible for up to three prior authorizations of up to 14 day supplies of opiates during the 12 month period
4. MaineCare members that are in Hospice care or are being treated for a diagnosis of Cancer, HIV or AIDS will be exempt from these limits
5. Post surgical members may receive prior authorizations for opiates up to 60 days in length if medical necessity is provided by the Surgeon
Please see the Pain Management Policy_Sec. 80 tab for the complete criteria
MISCELLANEOUS NARCOTICS
NARCOTICS - MISC.
MC/DEL
ACETAMINOPHEN/CODEINE
MC/DEL
8
ABSTRAL
MC/DEL
ASPIRIN/CODEINE TABS
MC/DEL
8
ASCOMP/CODEINE CAPS
MC/DEL
BUTAL/ASA/CAFF/COD CAPS
MC/DEL
8
BUTALBITAL/APAP/CAFFEINE/ CAPS
MC
8
DEMEROL
MC
BUTALBITAL/ASPIRIN/CAFFEI CAPS
MC
CAPITAL AND CODEINE SUSP1
MC/DEL
8
DILAUDID
MC
MC
8
DILAUDID-HP SOLN
MC/DEL
CAPITAL/CODEINE SUSP1
CODEINE PHOSPHATE SOLN
MC
8
FENTANYL CITRATE SOLN
MC/DEL
CODEINE SULFATE TABS
MC/DEL
8
FENTORA
MC/DEL
MC/DEL
8
FIORICET/CODEINE CAPS
MC/DEL
ENDOCET TABS3
ENDODAN TABS
MC
8
FIORINAL/CODEINE #3 CAPS
MC/DEL
FENTANYL OT LOZ1
MC
8
FIORTAL/CODEINE CAPS
MC/DEL
FENTANYL OT LOZ1
MC/DEL
8
HYDROCODONE/IBUPROFEN
MC/DEL
HYDROCODONE/ACETAMINOPHEN
MC
8
IBUDONE
MC/DEL
HYDROMORPHONE HCL3
MC/DEL
8
LORCET
MC
8
LORTAB
MC
8
MAXIDONE TABS
MC
MC/DEL
LORTAB ELX
MEPERIDINE HCL
MC/DEL
OXYCODONE
MC/DEL
8
NORCO TABS
MC/DEL
MC/DEL
8
NUCYNTA
MC/DEL
OXYCODONE/ACETAMINOPHEN2,3
PENTAZOCINE/NALOXONE TABS
MC/DEL
8
ONSOLIS
MC
PROPOXYPHENE CMPND-65 CAPS
MC/DEL
8
OXECTA
MC
PROPOXYPHENE COMPOUND CAPS
MC/DEL
8
OXYCODONE/APAP 10/650
MC/DEL
PROPOXYPHENE HCL CAPS
MC/DEL
8
OXYCODONE/APAP 7.5/500
MC/DEL
PROPOXYPHENE/ACET TABS
MC/DEL
8
PENTAZOCINE/ACET TABS
MC/DEL
PROPOXYPHENE-N/ACET TABS
MC
8
PERCOCET TABS
MC/DEL
ROXICET
MC
8
PERCOCET TABS
1. Fentanyl OT loz (Barr) Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
and Capital and codeine
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
suspension products require preferred drug(s) exists. Please refer to General Criteria category E.
PA for users over 18 years
of age. PA is not required if
under 18 years of age.
2. Oxycodone/acet 10/650
is 8 times more expensive.
Use twice as many of
oxycod/acet 5/325 instead.
You can mix andmatch
preferred strengths of
oxycodone and
oxycodone/acet to minimize
acet. dose similar to certain
non-preferred drugs.
Effective 1/01/2013, MaineCare will implement a 15 day limit for members prescribed opiates for their treatment of pain.
1. MaineCare members will be allowed over a rolling 12 month period up to a 15 day supply of an opiate without prior authorization
2. Members requiring longer than 15 days will require a PA for continuation of therapy and providers may provide medical necessity
3. Members may be eligible for up to three prior authorizations of up to 14 day supplies of opiates during the 12 month period
4. MaineCare members that are in Hospice care or are being treated for a diagnosis of Cancer, HIV or AIDS will be exempt from these limits
5. Post surgical members may receive prior authorizations for opiates up to 60 days in length if medical necessity is provided by the Surgeon
Please see the Pain Management Policy_Sec. 80 for the complete criteria
Page
3. Only preferred
manufacturer's products will
be available
35
of 58 without prior
authorization.
MC
OPIOID DEPENDENCE TREATMENTS
MC
ROXIPRIN TABS
SUBOXONE FILM
2
MC
8
PHRENILIN W/CAFFEINE/CODE CAPS
MC/DEL
8
ROXICET 5/500 TABS
MC
8
ROXICODONE TABS
MC
8
SYNALGOS-DC CAPS
MC
8
TALACEN TABS
MC
8
TREZIX
MC
8
TYLENOL/CODEINE #3 TABS
MC
8
TYLOX CAPS
MC
MC
8
8
XOLOX
VICODIN
MC
8
VICOPROFEN TABS
MC
8
ZYDONE TABS
MC
MC
9
ACTIQ LPOP
9
CONZIP
MC
9
OPANA
MC
3. Only preferred
manufacturer's products will
be available without prior
authorization.
Use PA Form# 20420
Use PA form #10300 for
PAs over the opiate limit
3
SUBOXONE TABS
Use PA Form# 10200 for
Suboxone Continuation
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 10100 for
Suboxone Restart
MC
MC/DEL
BUNAVAIL4
BUPRENORPHINE
1. Buprenorphine will only
be approved for use during
pregnancy.
MC
ZUBSOLV4
2. See Criteria Section
1,2
Suboxone Criteria
3. The manufacturer will be 1. Effective 1/1/2013, MaineCare will implement a 24 month lifetime limit for members prescribed Suboxone for the treatment of opioid addiction.
disconntinuing the tablets by 2. Prior authorization request will be reviewed for dose titration downward,whether the patient is engaged in recovery oriented support services,periodic urine drug screens, flim
the end of quarter one 2013. counts,factors that threaten stability of recovery or evidence of improvement is social,physical and occupational areas.
3. Members that stop treatment after 24 months and need to restart will require a prior authorization. This prior authorization will assess the patient risk of relapsing or evidence that the
patient has relapsed.
4. 24month lifetime limit for Members will continue to be required to follow the criteria listed below:
treatment of opioid addiction 1-Induction period for new starts max of 60 days
2-Max dose of 32 mg for induction
3-Max dose of 16 mg for maintenance
4-There is not more than one narcotic fill in member’s drug profile between today’s fill of suboxone and a prior suboxone fill within the past 90 days.
5- Prescribers limited to those with X-DEA
6- Should be evidence provided of monthly monitoring including random pill counts urine drug tests and prescription monitoring program reports.
7-Suboxone tablets will be available upon demonstrated allergy to the preferred product. Allergy may be established by 1) formal allergy testing by a board certified allergist or 2)
demonstration of hives after skin exposure for 24 hours to the Suboxone Film. (The product may be applied to the skin using a band-aid and member can be assessed after 24 hours
to ascertain the presence of hives by the prescriber).
NARCOTIC ANTAGONISTS
Page 36 of 58
NARCOTIC - ANTAGONISTS
MC/DEL
NALTREXONE HCL TABS
MC
MC
MC/DEL
EVZIO
Use PA Form# 20420
NALOXONE INJ
Use PA form# 30400 for
Vivitrol requests
Please see the criteria listed on the Vivitrrol PA form.
1
1. Will only be approved for
side effects experienced
with generic that are not
described in the literature as
occurring with the brand
version.
VIVITROL INJ
2
2. Please see the criteria
listed on the Vivitrrol PA
form. Any narcotics
attempting to be filled during
Vivitrol approval will require
prior authorization.
MC/DEL
MOBIC6
MC/DEL
MC/DEL
MOBIC SUSP6
6
RELAFEN TABS
MC/DEL
VIVLODEX
Approved without PA for patients 60 years old or over. Patients under 60 can use a preferred proton pump inhibitor with any preferred generic NSAID to achieve similar reductions in GI
Use PA Form# 10310
bleeding risk to that seen with the COX-II agents. Approvals for Celebrex will be granted for other requests based on failure of at least one generic NSAID from at least 2 different
1. Meloxicam has dosing
NSAID classes as described in the COX-II PA form. High risk GI bleeding patients must fail on adequate trials of safer agents (non-NSAID/Cox-2) for GI tract, such as acetaminophen.
limits allowing one tablet
daily of all strengths without
PA.
MC
REVIA TABS
COX 2 / NSAIDS
COX 2 INHIBITORS - SELECTIVE /
HIGHLY SELECTIVE
MC/DEL
CELEBREX CAPS 4,5,6
MC/DEL
KETOROLAC TROMETHAMINE
MC/DEL
NABUMETONE TABS
MC/DEL
2,3,6
6
MELOXICAM
1,6
2. Ketorolac Tromethamine
is indicated for the short
term (up to 5 days)
managment of moderately
severe acute pain that
requires analgesic at the
opiod level in adults. Not
indicated for minor of
chronic pain conditions.
3. Ketorolac has dosing
limits allowing 24 tablets for
a 5 day supply every 30
days.
4. Dosing limits will be set at
a maximum of 200mg twice
daily for PA requests.
5. Users 60 years of age or
older will not require PA. If
under 60 years of age,
Celebrex will require PA.
6. The FDA has issued a
Public Health Advisory
warning of the potential for
increased cardiovascular
risk & GI bleeding with
NSAID use.
NSAIDS
MC/DEL
CHILDRENS IBUPROFEN
MC
ADVIL TABS
MC/DEL
DICLOFENAC POTASSIUM TABS
MC
ANAPROX TABS
MC/DEL
DICLOFENAC SODIUM
MC
ANAPROX DS TABS
MC/DEL
ETODOLAC
MC
CAMBIA
MC/DEL
FENOPROFEN CALCIUM TABS
MC/DEL
CATAFLAM TABS
The FDA has issued a
Public Health Advisory
warning of the potential for
increased cardiovascular
risk & GI bleeding with
NSAID use.
Page 37 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Approvals will be granted for other requests based on failure of at least one generic NSAID from at least 3 different NSAID classes as described in the COX-II PA form.
increased cardiovascular
risk & GI bleeding with
NSAID use.
MC/DEL
FLURBIPROFEN TABS
MC
CHILDRENS ADVIL SUSP
MC/DEL
IBUPROFEN
MC
CHILD'S IBUPROFEN SUSP
MC/DEL
INDOMETHACIN
MC/DEL
CHILDREN'S MOTRIN SUSP
MC/DEL
KETOPROFEN
MC/DEL
CLINORIL TABS
MC/DEL
MECLOFENAMATE SODIUM CAPS
MC/DEL
DAYPRO TABS
MC/DEL
NAPROSYN SUSP
MC/DEL
EC-NAPROSYN TBEC
MC/DEL
NAPROXEN SUSP
MC/DEL
ETODOLAC ER 600MG
MC/DEL
NAPROXEN TABS
MC/DEL
NAPROXEN SODIUM TABS
MC/DEL
OXAPROZIN TABS
MC/DEL
SULINDAC TABS
MC/DEL
TOLMETIN SODIUM
MC/DEL
MOTRIN
MC
IBU-200
MC
INDOCIN
MC/DEL
LODINE
MC
NSAID - PPI
NAPRELAN TBCR
MC/DEL
NAPROSYN TABS
MC/DEL
NAPROXEN DR TBEC
MC/DEL
NAPROXEN SODIUM TBCR
MC
MC/DEL
PENNSAID
The FDA has issued a Public Health Advisory warning of the potential for increased cardiovascular risk & GI bleeding with NSAID use.
PIROXICAM CAPS
MC
PONSTEL CAPS
MC
SB IBUPROFEN TABS
MC
MC
SPRIX
TOLECTIN
VOLTAREN
MC
V-R IBUPROFEN TABS
MC
ZORVOLEX
MC
PREVACID NAPRA-PAC
VIMOVO1
MC/DEL
DDI: Diclofenac will now be non-preferred and require prior authorization if it is currently being used in combination with lescol.
NALFON CAPS
MC/DEL
MC/DEL
Use PA Form# 20420
FELDENE CAPS
MC/DEL
Approvals will be granted for other requests based on failure of at least one generic NSAID from at least 3 different NSAID classes as described in the COX-II PA form.
1. Use a preferred NSAID
and PPI separately.
Use PA Form# 20420
RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
MC/DEL
MC/DEL
ARAVA
HYDROXYCHLOROQUINE
LEFLUNOMIDE
MC/DEL
ACTEMRA
MC/DEL
CIMZIA
1
METHOTREXATE
MC/DEL
SULFASALAZINE TABS
1,4
ENBREL
MC/DEL
ENTYVIO
ILARIS2,5,6
MC
1
2
MC
2
HUMIRA1,2,4
1
MC/DEL
1
MC/DEL
1
MC/DEL
MC/DEL
AZATHIOPRINE
MC
KINERET SOLN
MC
ORENCIA
MC
MC
RASUVO7
MC
MC/DEL
REMICADE
SIMPONI
XELJANZ
See criteria as listed on Rheumatoid Arthritis PA form.
Use PA Form# 20900
1. Only one step 1 drug is
required to obtain Enbrel or Enbrel is preferred after a trial of a step 1 product (e.g. azathioprine, methotrexate, etc.); however, dosing limits will also still apply. Dosing limits will allow 8 injections per month without
Humira without PA.
pa. Use of greater than 8 injections per month will require PA.
2. Dosing limits apply.
Please see dose
consolidation list.
3. Preferred dosage form
Xeljanz is limited to adults with moderately to severely active RA who have had an inadequate response or intolerance to methotrexate. Should not be used concomitantly with
allowed without PA after trial biologic DMARDs or potent Immunosuppressants. Therapy should not be started in those with lymphocyte count <500cells/mm 3, an ANC <1000cells/mm3, or have a hemoglobin
of step 1 prodcuts is multi- <9g/dl.
dose vial, with dosing limits
allowing 8 injections per 28
days without pa.
4. Established users will be
grandfathered for Enbrel
and Humira.
5.Clinical PA is required to
establish diagnosis and
medical necessity.
6. Verification of age for
appropriate indication.
7. Treatment failure or
intolerance to other forms of
preferred methotrexate
Page 38 of 58
MISCELLANEOUS ARTHRITIS
ARTHRITIS - MISC.
MC/DEL
RIDAURA CAPS
MC
MC
ARTHROTEC
1
1. The individual
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
components of Arthrotec are on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
available without PA.
preferred drug(s) exists. The individual components of Arthrotec are available without PA.
MYOCHRYSINE SOLN
Use PA Form# 20420
LUPUS-SLE
LUPUS-SLE
MC
BENLYSTA
Use PA Form# 20420
D.H.E. 45 SOLN
Use PA Form# 10110
MIGRAINE THERAPIES
MIGRAINE - ERGOTAMINE DERIVATIVES
MIGRAINE - CARBOXYLIC ACID
DERIVATIVES
MIGRAINE - SELECTIVE SEROTONIN
AGONISTS (5HT)--Tabs
MIGRAINE - SELECTIVE SEROTONIN
AGONISTS (5HT)--Injectables
MC
MIGRANAL SOLN
MC
SANSERT TABS
MC
DIVALPROEX ER TB24
MC/DEL
MC
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DEPAKOTE ER TB24
Use PA Form# 10110
MC/DEL
1
RELPAX1
MC/DEL
1
MC
AXERT TABS
MC/DEL
1
RIZATRIPTAN TABS
SUMATRIPTAN TABS1
MC/DEL
FROVA TABS
MC/DEL
2
NARATRIPTAN HCI TABS1
MC/DEL
MC/DEL
IMITREX TABS1,2
MAXALT1,2,3
MC/DEL
MAXALT MLT1,2,3
MC/DEL
MC/DEL
RIZATRIPTAN ODT
MC/DEL
ZOMIG NASAL SPARY
3.Established users will be
grandfathered
MC/DEL
ZOMIG ZMT TBDP1,2
Use PA Form# 10110
MC/DEL
SUMATRIPTAN SOLN
Use PA Form# 10110
ZECUITY PATCH1,2
Use PA Form# 10110
MC/DEL
IMITREX KIT
MC/DEL
IMITREX SOLN
MC/DEL
IMITREX STATDOSE PEN KIT
MC/DEL
IMITREX STATDOSE REFILL KIT
MC/DEL
MC
Migraine-selective serotonin
agonists (5HT) transdermal
1. All drugs in this category
have dosing limits. Please
refer to dose consolidation
table.
1,2
AMERGE TABS
1,2
1,2
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Quantity limit exceptions will require ongoing therapy with therapeutic doses of highly effective prophylactic medication as listed on the Triptan PA form.
2. Must fail all preferred
products before nonpreferred.
ZOMIG TABS1,2
1,2
1. Dosing limits apply.
Please see dose
consolidation list.
2. Clinical PA required to
establish significant
contraindication to other
preferred and non-preferred
agents.
MIGRAINE - SELECTIVE SEROTONIN
AGONISTS (5HT)--Combinations
MC/DEL
TREXIMET
1,2
Use PA Form# 10110
1. Dosing limits apply.
Please see dose
consolidation list.
2. Use preferred
Sumatriptan and Naproxen
separately. Treximet only
available if component
ingredients of sumatriptan
and naproxen are
unavailable.
MIGRAINE - MISC.
MC/DEL
CAFERGOT TABS
MC/DEL
MIGRAZONE CAPS
MC/DEL
SPASTRIN TABS
MC
BELCOMP-PB SUPP
MC/DEL
Use PA Form# 10110
MIGERGOT SUP
GOUT
Page 39 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
GOUT
MC/DEL
ALLOPURINOL TABS
MC
MC/DEL
PROBENECID TABS
MC/DEL
MC/DEL
PROBENECID/COLCHICINE TABS
COLCRYS
ULORIC
1
MC
ZYLOPRIM TABS
MC
SENSORCAINE-MPF SOLN
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
Use PA Form# 20420
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
1. Failure of therapeutic
(300mg) dose of Allopurinol preferred drug(s) exists.
(failure define as not being
able to get uric acid levels
below 6mg/dl) or severe
renal disease.
MISC.
ANESTHETICS - MISC.
VACCINES
MC
MC
MC
MC/DEL
BUPIVACAINE HCL SOLN
LIDOCAINE HCL SOLN
MARCAINE SOLN
MC/DEL
MC
Use PA Form# 30130
SYNVISC INJ
XYLOCAINE SOLN
GARDASIL VACCINES
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Under the Maine Immunization Program Gardasil is covered under the Vaccine for Children Program for ages 9-18. Gardasil will be preferred by MaineCare for ages 19-26. Children
who are 18 years old or younger are eligible for this vaccine through the Maine Immunization Program. Please contact 1-800-867-4775 or 207-287-3746 for assistance.
ANTI-CONVULSANTS
ANTICONVULSANTS
MC/DEL
CARBAMAZEPINE
CARBATROL CP12
MC
MC
8
MC/DEL
8
APTIOM
BANZEL
MC/DEL
CELONTIN CAPS
MC
8
DEPAKENE
MC/DEL
CLONAZEPAM TABS
MC
MC
8
8
DEPAKOTE
DEPAKOTE ER
MC
MC/DEL
DEPAKOTE SPRINKLES CPSP
DIASTAT1
DILANTIN
MC/DEL
8
DIAZEPAM GEL
MC/DEL
MC/DEL
8
DIVALPROEX SODIUM SPRINKLE CAPS
MC/DEL
DIVALPROEX SODIUM
MC/DEL
8
EQUETRO
MC/DEL
EPITOL TABS
MC/DEL
8
GABITRIL TABS
MC/DEL
ETHOSUXIMIDE SYRP
MC/DEL
8
HORIZANT
MC/DEL
FELBATOL
MC/DEL
8
GABAPENTIN 600mg & 800mg
MC
MC/DEL
FYCOMPA
MC
8
GRALISE
GABAPENTIN2 300mg & 400mg
MC/DEL
8
KEPPRA TABS
MC/DEL
LAMOTRIGINE2
MC/DEL
8
KEPPRA SOLN
MC/DEL
LEVETIRACETAM SOLN/TABS
MC/DEL
8
KLONOPIN TABS
MC/DEL
MC/DEL
OXCARBAZEPINE
PHENYTEK CAPS
MC/DEL
8
LAMICTAL
MC/DEL
8
LEVETIRACETAM INJ
MC/DEL
PHENYTOIN
PRIMIDONE TABS
MC/DEL
MC/DEL
8
8
LEVETIRACETAM ER TABS
MC/DEL
MC/DEL
TEGRETOL
MC/DEL
8
MC/DEL
TOPIRAMATE
MC
8
MC/DEL
MC
8
ONFI
OXTELLAR XR7
MC/DEL
TOPIRAMATE SPRINKLE CAPS2
TRILEPTAL SUSP
MC/DEL
VALPROIC ACID
MC/DEL
MC
8
8
POTIGA
SABRIL
MC/DEL
VALPROIC ACID
MC
8
TOPAMAX
MC/DEL
MC/DEL
VIMPAT4
MC
8
TOPAMAX SPRINKLE CAPS2
ZONISAMIDE
MC
8
MC/DEL
8
TROKENDI2,8
TRILEPTAL
MC/DEL
8
ZARONTIN SYRP
MC/DEL
9
KEPPRA XR 5,6
MC/DEL
MC/DEL
9
NEURONTIN
9
MC/DEL
9
TEGRETOL-XR TB12 5,6
ZONEGRAN CAPS
MC/DEL
9
LAMICTAL XR
2
LYRICA3
MYSOLINE TABS
Use PA Form# 20420
One time PA is required to determine seizure diagnosis for any non-preferred anticonvulsant. Other approvals will be for patients with a variety of drug-specific FDA-approved
All non-preferred meds must indications and for specific conditions supported by at least two published peer-reviewed double-blinded, placebo-controlled randomized trials that are not contradicted by other studies
be used in specified order of similar quality after recommendation by the DUR Committee and as long as all first line therapies have been tried and failed at full therapeutic doses for adequate durations (at least
two weeks).
1. Quantity limit. 5/month
2. Dosing limits apply,
please see dose
consolidation list.
3. Dosing limits apply per
strength as well as a
maximum daily dose of
600mg. Please see dose
consolidation list.
*** SEE CHART AT END OF DOCUMENT
Topamax and Neurontin - Second line therapy for migraine prophalaxis after trial of at least three preferred preventive medications from Group 1 listed on page 2 of the Acute Migraine
PA form.
Lyrica- Second line therapy for Diabetic Peripheral Neuropathy and Post Herpetic Neuralgia. With Fibromyalgia diagnosis, Lyrica will not require PA if previous 4 week trials of the
4. Adjunctive therapy 17 and following three are seen in drug profile at full therapeutic doses: TCA or cyclobenzaprine, gabapentin, and savella.
older.
5. Current users as of
7/30/10 for seizures will be
grandfathered.
All non-preferred meds must be used in specified order.
DDI: Any Carbamazepine formulation will now be non-preferred and require prior authorization if any of the following drugs are currently being used in combination with
6. Product is considered line carbamazepine: Abilify, clarithomycin, clozapine, erythromycin, Latuda, Seroquel, telithromycin or Zyprexa.
extension of the original
product due to Healthcare
Reform (HCR). MaineCare
Please use Drug-Drug Interaction PA form #10400 for this combination.
will consider these
medications non-preferred
and a step 9 because of the
impact under the Federal
ONFI will require a clinical PA to confirm LGS diagnosis
Rebate Program in
conjunction with HCR.
7. Max dose 2400mg
8. Clinical PA required for
appropriate diagnosis
Page 40 of 58
BIPOLAR DISORDER: STEP ORDER
M ~ A
4 ~ 4
4 ~ 4
LAMICTAL
LITHIUM
4 ~ 4
CARBAMAZEPINE
4 ~ 4
VALPROATE
4 ~ 4
ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE
5 ~ 5
TRILEPTAL
9 ~ 6
TOPAMAX
9 ~ 7
KEPPRA TABS
9 ~ 8
GABITRIL TABS
9 ~ 9
NEURONTIN
9 ~ 9
ZONEGRAN CAPS
SEE ANTICONVULSANT
INDICATION CHART AT
THE END OF THIS
DOCUMENT
M= Monotherapy
A= Adjunctive
9= No Evidence
The step orders show the
relative strength of evidence
for use in bi-polar and will
guide prior authorization
determinations.
Step 4 drugs-no PA
required.
PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER
M ~ A
(6-18 YEARS WITH OR WITHOUT PSYCHOSIS)
4 ~ 4
LITHIUM
4 ~ 4
CARBAMAZEPINE
4 ~ 4
VALPROATE
4 ~ 4
ATYPICAL ANTIPSYCHOTICS EXC.CLOZAPINE
4 ~ 4
LAMICTAL
TRILEPTA
5 ~ 5
Two-step 1 preferred drugs
must be tried before
Trileptal.
The step orders show the
relative strength of evidence
for use in bi-polar and will
guide prior authorization
determinations.
Step 4 drugs-no PA
required.
ANTI-PARKINSON DRUGS
PARKINSONS - ANTICHOLINERGICS
MC/DEL
MC
BENZTROPINE MESYLATE TABS
Use PA Form# 20420
COGENTIN SOLN
MC/DEL
TRIHEXYPHENIDYL
PARKINSONS - COMT INHIBITORS
MC/DEL
COMTAN TABS
MC/DEL
PARKINSONS - SELECTED DOPAMIN
AGONISTS
MC/DEL
PRAMIPEXOLE
MC/DEL
5
MC/DEL
ROPINIROLE
MC/DEL
8
MIRAPEX TABS
REQUIP TABS
MC/DEL
8
REQUIP XL TABS
MC/DEL
8
MIRAPEX ER
MC/DEL
8
NEUPRO PATCH
TASMAR TABS
Use PA Form# 20420
PARKINSONS DOPAMINERGICS/CARBII/ LEVO
MC/DEL
AMANTADINE HCL
MC/DEL
BROMOCRIPTINE MESYLATE TABS
MC/DEL
CARBIDOPA/LEVODOPA TABS3
CARBIDOPA/LEVODOPA ER
MC/DEL
PARKINSONS - COMBO.
1
MC/DEL
APOKYN3
MC
AZILECT2
MC/DEL
MC
BROMOCRIPTINE MESYLATE CAPS
ELDEPRYL CAPS
MC
LARODOPA TABS
MC
MC/DEL
PARLODEL CAPS
MC/DEL
PARLODEL TABS
MC/DEL
SELEGILINE CAPS HCL
MC
MC/DEL
RYTARY
SELEGILINE TABS HCL
LODOSYN TABS
Preferred drug must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Preferred drug must be tried and failed in step-order due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
Use PA Form# 20420
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
1. As of 12/08 users of
another drug and the preferred drug(s) exists.
Mirapex will be
grandfathered if diagnosis is
Parkinsons.
1. Approvals will require
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
concurrent therapy with
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
Levodopa and failed trials of preferred drug(s) exists.
Selegiline, Comtan, and
Stalevo.
2. Approvals will require
trials of
Carbidopa/Levodopa,
Selegiline, Comtan, and
Stalevo.
MC
SINEMET TABS
MC
SINEMET TBCR
3. Only preferred
manufacturer's products will
be available without prior
authorization.
MC
ZELAPAR1
Use PA Form# 20420
MC/DEL
STALEVO1
Use PA Form# 20420
Page 41 of 58
MC
CARBIDOPA/LEVODOPA/ENTACA
1
1.Clinical PA is required to
establish diagnosis and
medical necessity.
MUSCLE RELAXANTS
ALS DRUG
MC/DEL
RILUZOLE
MC/DEL
MUSCLE RELAXANTS
MC/DEL
BACLOFEN TABS
MC/DEL
CHLORZOXAZONE TABS
MC/DEL
MC/DEL
6
7
SKELAXIN TAB
ORPHENADRINE CITRATE
MC/DEL
CYCLOBENZAPRINE HCL TABS
MC/DEL
8
CARISOPRODOL 350MG TABS
LIORESAL INTRATHECAL KIT
MC/DEL
8
AMRIX
MC/DEL
METHOCARBAMOL TABS
MC/DEL
8
DANTRIUM CAPS
MC/DEL
TIZANIDINE HCL TABS
MC
8
LIORESAL TABS
MC
8
LORZONE
MC/DEL
MC
8
8
METAXALONE
NORFLEX TBCR
MC
8
ROBAXIN-750 TABS
MC
8
8
VECUROMIUM INJ
ZANAFLEX TABS
9
CARISOPRODOL 250MG TABS
9
MC
MC/DEL
MC/DEL
MC/DEL
MUSCLE RELAXANT - COMBO.
RILUTEK TABS
Use PA Form# 20420
At least 4 preferred drugs (including tizanidine) must be tried for at least 2 weeks and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be
approved, unless an…… acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
significant potential drug interaction between another drug and the preferred drug(s) exists. Elderly patients, over 65, will require written notice of the increased sedative risks and
impaired driving.Prior Authorization will not be given for:1. frequent or persistent early refills of controlled drugs; 2. multiple instances of early refill overrides due to reports of
misplacement, stolen, dropped in toilet or sink, distant travel, etc.
Non-preferred drugs will not be approved if members circumventing MaineCare prior authorization requirements by paying (prescribers failed to submit prior authorization prior to cash
narcotic scripts being filled by member).
Non-preferred products must be used in specified step order.
Lorzone is non preferred and requires at least 4 preferred drugs (including tizanidine) and step care therapy (orphenadrine), as well as reasons for why chlorzoxazone is not
acceptable.
SOMA TABS
Use PA Form# 20420
MC/DEL
CARISOPRODOL/ASPIRIN TABS
Use PA Form# 20420
MC/DEL
CARISOPRODOL/ASPIRIN/CODE
MC
NORGESIC TABS
MC/DEL
ORPHENADRINE COMPOUND
MC/DEL
ORPHENADRINE/ASA/CAFF
MC
Individual components are available with PA described in the section above.1. frequent or persistent early refills of non-controlled drugs; 2. multiple instances of early refill overrides
due to reports of misplacement stolen, dropped in toilet or sink, distant travel, etc.
ORPHENGESIC
PARATHYROID HORMONE
PARATHYOID HORMONE
MC
NATPARA1
1. Recommended only for
those who cannot be wellcontrolled on calcium
supplements and active
forms of vitamin D alone.
ASCORBIC ACID TABS
MC
AQUASOL E SOLN
MC
BIOTIN
MC
AQUAVIT-E SOLN
MC
MC
CYANOCOBALAMIN SOLN
MC
DHT SOLN
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
Use PA Form# 20420
Please refer to OTC list for on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
covered products.
FERIVA CAP
MC
NASCOBAL GEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
interaction between another drug and the preferred drug(s) exists.
VITAMINS
VITAMINS
MC/DEL
FERIVAFA CAP
Click here for the OTC List
MC
MC
FERRALET 90 TAB
MC/DEL
MC
FOLIC ACID TABS
FUSION PLUS CAP
MC
HEMOCYTE PLU CAP
MC
INTEGRA CAP
MC
INTEGRA PLUS CAP
MC
MC/DEL
INTEGRA F CAP
MEPHYTON TABS
MC/DEL
NIACIN
MC
MC/DEL
MC
MC/DEL
Please refer to OTC list for covered products.
DDI: B-12 will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently non
preferred PPI.
NIACOR TABS
NICOTINIC ACID SR CPCR
Preferred products that used to require diag codes still require diag codes unless indicated otherwise.
PYRIDOXINE HCL TABS
SLO-NIACIN TBCR
MC
TANDEM CAP
MC
TANDEM PLUS CAP
Page 42 of 58
MC/DEL
THIAMINE HCL SOLN
MC/DEL
VITAMIN B-1 TABS
MC/DEL
VITAMIN B-12
MC
VITAMIN D's
VITAMIN B-6 TABS
MC/DEL
VITAMIN C
MC/DEL
VITAMIN E CAPS
MC/DEL
VITAMIN E/D-ALPHA CAPS
MC
VITAMIN K1 SOLN
MC
V-R VITAMIN E CAPS
MC/DEL
CALCITRIOL CAPS1
VITAMIN D
MC/DEL
ZEMPLAR TABS
MC/DEL
MC
DRISDOL CAPS
1. Diagnosis of dialysis
(renal failure) required.
Preferred products require dialysis/renal failure diagnosis.
CALCIJEX
MC/DEL
HECTOROL (ORAL)
Use PA Form# 20420
<12.2mg/dl, corrected calcium x phosphorous products <70mg /dl
MC/DEL
HECTOROL (PARENTERAL)
MC/DEL
ROCALTROL
MC
ZEMPLAR INJ
MC
Non-preferred products require: Secondary hyperparathyroidism in patients with Chronic Kidney Disease on dialysis., iPTH>400 pg/ml, Phosophorous ,6.5mg/dl, corrected calcium
2
2
MISC MULTI-VITAMINS
VITAMINS - MISC.
MC
CENTRUM LIQD
MC
MC
CENTRUM TABS
MC/DEL
ADVANCED NATALCARE TABS
MC
CENTRUM JR/IRON CHEW
MC
MC
CENTRUM SILVER TABS
MC
AQUADEKS
CENTRUM JR/EXTRA C CHEW
MC
CENTRUM-LUTEIN TABS
MC
CENTRUM PERFORMANCE TABS
MC
CEROVITE ADVANCED FO TABS
MC/DEL
CITRANATAL
DALYVITE LIQD
ADEKS
CHEWABLE MULTIVIT/FL CHEW
MC
MC
MC
COD LIVER OIL CAPS
MC
EMBREX 600 MISC
MC
COMPLETE SENIOR TABS
MC
IBERET
MC
DAILY MULTI VIT/IRON
MC
MATERNA TABS
MC/DEL
MC/DEL
DIALYVITE 1MG
DIALYVITE 800MG
MC
MAXARON
MC
MULTIRET FOLIC -500 TBCR
MC
MC/DEL
FERRALET 90
FULL SPECTRUM B
MC/DEL
NATAFORT TABS
MC/DEL
NATALCARE CFE 60 TABS1
MC
M.V.I.-12 INJ
MC/DEL
NATALCARE GLOSS TABS1
MC
MULTI-VIT/FLUORIDE
MC
NATALCARE PIC TABS1
MC/DEL
NATALCARE RX TABS
MC
NATALCARE PIC FORTE TABS1
MC/DEL
MC/DEL
NEPHRONEX
MC/DEL
NATALCARE PLUS TABS1
MC/DEL
O-CAL PRENATAL
ONE DAILY TABS
MC
MC/DEL
NATALCARE THREE TABS1
NATACHEW CHEW
MC/DEL
ONE-DAILY MULTIVITAMINS
MC
NATALFIRST TABS
MC/DEL
ONE-TABLET-DAILY
MC
NATATAB RX TABS
MC/DEL
POLY-VIT/IRON/FLUORID SOLN
MC/DEL
NEPHPLEX RX TABS
MC/DEL
POLY-VITAMIN/FLUORIDE SOLN
MC/DEL
NEPHROCAPS CAPS
MC/DEL
POLY-VITAMINS/IRON SOLN
MC/DEL
NEPHRO-VITE TABS
MC/DEL
PRENATAL TABS1
MC
NESTABS RX TABS
MC/DEL
PRENATAL FORMULA 3 TABS1
MC/DEL
NIFEREX
MC/DEL
PRENATAL PLUS TABS1
MC/DEL
OCUVITE TABS
MC/DEL
PRENATAL PLUS NF TABS1
MC
POLY-VI-FLOR SOLN
MC
PRENATAL PLUS/27MG IRON1
MC
POLY-VI-SOL SOLN
MC
PRENATAL PLUS/IRON TABS1
MC
POLY-VI-SOL/IRON SOLN
PRENATAL RX/BETA-CAROTENE1
RENAL CAPS
MC
POLY-VITAMIN DROPS SOLN
MC
PRECARE
RENAPHRO CAPS
STRESS TAB NF TABS
MC
MC
PREFERA OB
PREMESIS RX TABS
MC
THERAPEUTIC-M TABS
MC
PRENATABS CBF TABS1
MC
THERAVITE LIQD
MC
PRENATAL CARE TABS1
TRI-VITAMIN/FLUORIDE SOLN
MC
PRENATAL MR 90 TBCR1
MC/DEL
MC/DEL
MC/DEL
MC
MC/DEL
MC
VITA CON FORTE CAPS
MC
VITAMIN B COMPLEX CAPS
MC/DEL
MC
1. Diag codes are no longer Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
required on prenatal
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
vitamins.
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
Please refer to OTC list.
Please refer to OTC list.
Use PA Form# 20420
Preferred products that used to require diag codes still require diag codes unless indicated otherwise.
Click here for the OTC List
PRENATAL MTR/SELENIUM TABS1
PRENATAL OPTIMA ADVANCE TABS1
Page 43 of 58
MC
MC
VITAPLEX PLUS TABS
MC/DEL
PRENATAL PC 40 TABS
PRENATAL RX TABS
MC
PRENATE
MC
PRENATE ELITE1
PRIMACARE MISC
MC
MC
1
1
1
PROTEGRA CAPS
MC
STUARTNATAL PLUS 3 TABS1
TRI-VI-SOL SOLN
MC
TRI-VI-SOL/IRON SOLN
MC
MC/DEL
ULTRA NATALCARE TABS
MC
ULTRA-NATAL TABS1
VICON FORTE CAPS
MC
VINATAL FORTE TABS
MC
MC
MC/DEL
1
1
VINATE
VINATE ADVANCED TABS
1
MISCELLANEOUS MINERALS
MINERALS
MC
CALCARB
MC
ANEMAGEN
MC
CALCI-MIX CAPSULE CAPS
MC
CALCET TABS
MC
CALCIQUID SYRP
MC/DEL
Use PA Form# 20420
Please refer to OTC list.
CALCIUM 600-D TABS
CALCITRATE/VITAMIN D TABS
MC
CALCIUM/VITAMIN D TABS
MC/DEL
CALCIUM
MC
CALTRATE 600 PLUS/VIT D TABS
MC/DEL
CALCIUM CARBONATE
MC
CALTRATE PLUS TABS
MC/DEL
CALCIUM CITRATE TABS
MC
CHROMAGEN
MC/DEL
CALCIUM GLUCONATE TABS
MC
CITRACAL PLUS TABS
MC/DEL
CALCIUM LACTATE TABS
MC
CONTRIN CAPS
CALCIUM/MAGNESIUM TABS
MC
FEOGEN FORTE CAPS
MC
FEROCON CAPS
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
Click here for the OTC List
MC
MC
MC/DEL
MC
CALCIUM/VITAMIN D TABS
CALTRATE 600 TABS
MC/DEL
CHEWABLE CALCIUM CHEW
MC
FERRO-SEQUELS TBCR
CITRACAL TABS
MC
FE-TINIC CAPS
MC
CITRACAL + D TABS
MC
FE-TINIC 150 FORTE CAPS
MC
CITRUS CALCIUM TABS
MC
CITRUS CALCIUM 1500 + D TABS
MC
EFFERVESCENT POTASSIUM TBEF
MC/DEL
MC
MC/DEL
HEMOCYTE TABS
K-DUR TBCR
FEOSTAT CHEW
MC
KLOR-CON PACK
MC
FERATAB TABS
MC
K-LYTE
FER-GEN-SOL SOLN
MC/DEL
K-PHOS TABS NEUTRAL
MC
FER-IRON SOLN
MC
K-TABS TBCR
MC
FERRONATE TABS
MC
K-VESCENT PACK
MC/DEL
FERROUS SULFATE
MC
MICRO-K 10 MEG CPCR
MC/DEL
FLUOR-A-DAY CHEW
MC
NU-IRON 150 CAPS
MC
FLUORIDE CHEW
MC/DEL
OYSTER SHELL CALCIUM/VITA TABS
MC
FLUORIDE SODIUM CHEW
MC/DEL
POLY-IRON 150 CAPS
MC
FLUORITAB CHEW
MC/DEL
POLYSACCHARIDE IRON CAPS
MC
HM CALCIUM TABS
MC/DEL
POTASSIUM BICARB/CHLORIDE
MC
K+ POTASSIUM PACK
MC/DEL
POTASSIUM CHLORIDE 10MEQ CAPS
MC
KAON ELIX
MC/DEL
POTASSIUM CHLORIDE 8MEQ CAPS
MC
KAON-CL-10 TBCR
MC/DEL
SLOW FE TBCR
MC
KCL 0.075%/D5W/NACL 0.2% SOLN
MC
TUMS 500 CHEW
MC
K-EFFERVESCENT TBEF
MC
VIACTIV CHEW
MC
KLOR-CON
MC
KLOTRIX TBCR
MC/DEL
K-PHOS TABS
MC/DEL
K-VESCENT TBEF
Preferred products that used to require diag codes still require diag codes unless indicated otherwise.
FLUOR-A-DAY SOLN
MC/DEL
MC/DEL
Please refer to OTC list.
FERREX 150 CAPS
MC
MC/DEL
DDI: Fe salts will now be non-preferred and require prior authorization if it is currently being used in combination with either Prevacid, pantoprazole, Prilosec, or any currently non
preferred PPI.
Page 44 of 58
MC/DEL
LURIDE CHEW
MC/DEL
MAGNESIUM GLUCONATE TABS
MC/DEL
MAGNESIUM SULFATE SOLN
MC
MAGTABS
MC
MICRO-K 8 MEG
MC/DEL
OS-CAL TABS
MC/DEL
OS-CAL 500 + D TABS
MC/DEL
OYSCO
MC/DEL
OYST-CAL TABS
MC/DEL
OYST-CAL D TABS
MC/DEL
OYST-CAL/VITAMIN D TABS
MC/DEL
OYSTER CALCIUM TABS
MC/DEL
OYSTER SHELL
MC
PHARMA FLUR
MC/DEL
MC
PHOSPHA 250 NEUTRAL TABS
POTASSIUM BICARBONATE TBEF
MC/DEL
POTASSIUM CHLORIDE 8MEQ
MC
POTASSIUM EFFERVESCENT
MC/DEL
SELENIUM TABS
MC
SLOW-MAG TBCR
MC/DEL
SODIUM FLUORIDE
MC/DEL
SSKI SOLN
MC
V-R CALCIUM
MC
V-R OYSTER SHELL CALCIUM
MC
ZINC SULFATE CAPS
MC
INTRALIPID EMUL1
MISC. ELECTROLYTES/NUTRITIONALS
ELECTROLYTES/ NUTRITIONALS
MC
MC/DEL
P.T.E. -5 SOLN
1
1
SEA-OMEGA CAPS
MC
BOOST1
MC
CASEC POWD
MC
CHOICE DM LIQD
MC
DELIVER 2.0 LIQD1
MC
ENFAMIL1
MC
ENSURE1
MC
GLUCERNA1
MC
ISOCAL LIQD1
MC
KINDERCAL TF LIQD1
MC
KINDERCAL TF/FIBER LIQD1
MC/DEL
PROCRIT SOLN1
1. This list of nutritionals is
incomplete. All nutritionals
still require a PA except for
the miscellaneous products
listed as preferred. SGA
form required for nutritionals
unless member has a G/I
tube.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. As listed in MaineCare Policy, certain drugs require specific diagnoses for approval.
2. Formerly known as
Omacor.
For children under the age of 5, MaineCare will not provide milk- or soy-based standard infant formulas. Regular formulas may be sought through your nearest WIC office. MaineCare
will continue to cover medical food for all participants in MaineCare when medical necessity is met.
Medical foods are not to be authorized solely for the purpose of enhancing nutrient intake or managing body weight if the participant is able to eat conventional foods adequately.
Medical foods may be approved if the member has a medical condition which precludes or restricts the use of conventional foods and necessitates the use of a formula. Concurrent
Stimulant therapy is not an acceptable medical reason/condition for use of medical foods for enhancing nutrient intake or managing body weight.
MC
LIPISORB LIQD1
MC
LOVAZA1,2
Use PA Form# 20420
MC
MODULEN IBD POWD1
& SGA Form
MC
NUTRAMIGEN POWD1
Vascepa requires adjunct therapy for specific indication to reduce TG in those with severe hypertriglyceridemia (500mg per deciliter or more). Proper indication per lab values is
required before approval
Use PA Form# 10520
Non-Preferred drugs must be tried and failed in step-order, due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
another drug and the preferred drug(s) exists. Please see the EPO PA form for other approval and renewal criteria.
NUTREN1
MC
NUTRITIONAL SUPPLEMENT LIQD1
MC
NUTRIVENT 1.5 LIQD1
MC/DEL
PEPTAMEN1
MC
PHENYLADE1
MC
PHENYL-FREE1
MC
PKU 3 POWD1
MC
PREGESTIMIL POWD1
MC/DEL
PROBALANCE LIQD1
MC
PROSOBEE
MC
SCANDISHAKE PACK1
VASCEPA
1
MC
MC
1
L-CARNITINE CAPS1
MC/DEL
ERYTHROPOEITINS
1
MC
6
EPOGEN SOLN
Page 45 of 58
MC
8
ARANESP SOLN
MC/DEL
8
MIRCERA
MC/DEL
8
OMONTYS
MC
8
LEUKINE
MC
MC
8
NEUPOGEN SOLN2
9
NEULASTA
ZARXIO
1
Non-Preferred drugs must be tried and failed in step-order, due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
1. Clinical PA is required to exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between
establish medical necessity another drug and the preferred drug(s) exists. Please see the EPO PA form for other approval and renewal criteria.
and that appropriate lab
monitoring is being done.
GRANULOCYTE CSF
GRANULOCYTE CSF
MC/DEL
1
1. Must be used in specified See approval criteria detailed on Neupogen PA form.
step order.
2.10 day supply/month may
be used without a PA.
Use PA Form# 20520
GAUCHER DISEASE
GAUCHER DISEASE
MC
CERDELGA
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Exceeding days supply limits for LMWH class requires PA.
Use PA Form# 20420
ANTICOAGULANTS / PLATELET AGENTS
ANTICOAGULANTS
MC
MC/DEL
LOVENOX SOLN
ENOXAPARIN1
ELIQUIS
COUMADIN TABS
MC/DEL
FONDAPARINUX
MC
IPRIVASK
MC/DEL
JANTOVEN
MC/DEL
LOVENOX 3002
MC
FRAGMIN INJ1
HEPARIN SODIUM/NACL 0.9% SOLN
MC/DEL
WARFARIN SODIUM TABS3
MC
HEP-LOCK SOLN
MC/DEL
SAVAYSAS
MC/DEL
MC/DEL
MC
MC/DEL
MC/DEL
MC
ARIXTRA SOLN
1
2. Use other strengths
available to obtain desired
dose.
HEPARIN LOCK SOLN
HEPARIN LOCK FLUSH SOLN
MC/DEL
HEPARIN SODIUM SOLN
MC/DEL
PRADAXA
MC/DEL
XARELTO
MC/DEL
HEPARIN SODIUM LOCK FLUSH SOLN
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Exceeding days supply limits for LMWH class requires PA.
DDI: Warfarin will require prior authorization if being used in combination with fluconazole, miconazole, or voriconazole.
4
INNOHEP
MC/DEL
1. Arixtra, Fragmin and
Enoxaparin therapy
durations greater than 7
days require PA.
DDI: Warfarin will require prior authorization if being used in conjunction with Gemfibrozil or Fenofibrate.
3.Established users will be
grandfathered, new starters
must use preferred product
DDI: Rifampin will require prior authorization if being used in combination with Savaysa
Coumadin.
4. Diagnosis required
Use PA form# 20725 for
Pradaxa requests
ANTIHEMOPHILIC AGENTS
MC
ALPHANATE
MC
MC/DEL
ALPHANINE SD
BENEFIX SOLR
MC/DEL
HELIXATE FS KIT
MC
MC
HEMOFIL - M
HUMATE-P SOLR
MC
KOGENATE FS
MC
KONYNE - 80
MC
MONARC - M
MC
MONOCLATE - P
MC
MONONINE
NOVOSEVEN SOLR
MC
MC/DEL
MC
MC
ADVATE1,2
KOATE-DVI
Use PA form# 20420 for
other requests
1. Only if other products
unavailable.
2. Advate may be available
with PA in cases of large
volume dosing in patients
with poor venous access.
Use PA Form# 20420
PROFILNINE
MC
RECOMBINATE SOLR
MC
REFACTO
Page 46 of 58
Non-preferred will only be approved if other preferred products are unavailable.
MC
PLATELET AGGREGATION INHIBITORS
WILATE INJ
MC/DEL
ASPIRIN
MC/DEL
7
TICLOPIDINE HCL TABS
MC/DEL
DIPYRIDAMOLE TABS
MC
8
MC/DEL
CLOPIDOGREL 75MG
MC/DEL
8
EFFIENT1
PERSANTINE TABS
MC/DEL
8
BRILINTA1,2
MC/DEL
8
MC/DEL
8
1
PLAVIX TABS
ZONTIVITY
Use PA Form# 20715 for
Plavix,Effent & Brilinta
Use PA form# 20420 for
other requests
1. A special PA may be
obtained at the pharmacy
for members scheduled for
"stent" placement or have
had placement if in the last
12months. Please indicate
on prescription date of stent
placement.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
A special PA may be obtained at the pharmacy for members scheduled for "stent" placement or have had placement if in the last 12months. Please indicate on prescription date of
stent placement.
DDI: Plavix will require prior authorization if being used in combination with omeprazole, esomeprazole, cimetidine, fluconazole, ketoconazole, intelence, fluoxetine, ticlopidine, and
fluvoxamine.
DDI: exists for using maintenance ASA dose >100mg, as it reduces the effectiveness of Brilinta
Brilianta- Concomitant use with strong CYP3A4 inhibitors should be avoided (including ketoconazole, itraconazole, atazanavir, and telithromycin). Doses of simvastatin and lovastatin
>40mg should be avoided.
2. Dosing limits apply,
please see dose
consolidation list.
PLATELET AGGR. INHIBITORS /
COMBO'S - MISC.
MC/DEL
AGGRENOX
MC/DEL
AGRYLIN CAPS
MC/DEL
CILOSTAZOL
MC/DEL
ANAGRELIDE CAPS
MC/DEL
PENTOXIFYLLINE ER TBCR
MC/DEL
PLETAL TABS
MC
TRENTAL TBCR
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
A diagnosis of Paroxysmal nocturnal hemoglobinuria (PNH) using the HAM test or flow cytometry is required. In addition, the patient must show evidence of having received a
meningitis vaccine at least 2 weeks prior to the start of therapy.
HEMATOLOGICALS
MONOCLONAL ANTIBODY
IMMUNE GLOBULIN INTRAVENOUS
(IVIG)
MC
OCTAGAM INJ1
BRADYKININ B2 RECEPTOR
ANTAGONIST
MC
SOLIRIS
Use PA Form# 20420
MC
GAMMAPLEX INJ
Use PA Form# 20420
1. Clinical PA required
MC
FIRAZYR
Use PA Form# 20420
HEMATOLOGICAL AGENTSTHROMBOPOIETIN RECEPTOR
AGONISTS
MC/DEL
MC
7
8
PROMACTA
NPLATE
Use PA Form# 20420
Clinical PA required. Must see prior trial with insufficient response to corticosteroids and immunoglobulins.
HEMOSTATIC
HEMOSTATIC
MC/DEL
AMICAR
Use PA Form# 20420
MC
AMINOCAPROIC ACID
MC
AK-SPORE OINT
MC
AK-POLY-BAC OINT
MC
BACITRACIN OINT
MC
AK-SULF OINT
MC
BACITRACIN/NEOMYCIN/POLYM
MC
AK-TOB SOLN
MC/DEL
BACITRACIN/POLYMYXIN B OINT
MC
AZASITE
CHLOROPTIC SOLN
MC
BLEPH-10 SOLN
MC/DEL
ERYTHROMYCIN OINT
MC
GENTAK
MC/DEL
GENTAMICIN SULFATE
MC
ILOTYCIN OINT
MC/DEL
NEOMYCIN/POLYMYXIN/GRAMIC
OPHTHALMICS
OP. - ANTIBIOTICS
MC
OP. - QUINOLONES
MC/DEL
NEOSPORIN SOLN
MC
NEOSPORIN OINT
MC
POLYSPORIN
MC
OCUSULF-10 SOLN
MC/DEL
SODIUM SULFACETAMIDE SOLN
MC
OCUTRICIN SOLN
MC/DEL
SULFACETAMIDE SODIUM
MC
TERAK OINT
MC/DEL
TRIMETHOPRIM SULFATE/POLY
MC/DEL
TOBRAMYCIN SULFATE SOLN
MC/DEL
VIROPTIC SOLN
MC/DEL
TOBREX OINT
MC/DEL
TRIFLURIDINE SOLN
MC/DEL
CILOXAN SOLN
MC
OCUFLOX SOLN
CILOXAN OINT
MC/DEL
CIPROFLOXACIN SOL 0.3%
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
NEOMYCIN/BACI/POLYM OINT
MC
MC/DEL
Use PA Form# 20420
Page 47 of 58
OP.QUINOLONES-4TH GENERATION
OP. - ARTIFICIAL TEARS AND
LUBRICANTS
MC/DEL
BESIVANCE
MC/DEL
OFLOXACIN
MC/DEL
QUIXIN SOLN
MC/DEL
MC/DEL
VIGAMOX
MOXEZA
MC
AKWA TEARS OINT
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC
ZYMAXID
Use PA Form# 20420
MC
AKWA TEARS SOLN
Use PA Form# 20420
1. Dosing limits apply,
please see dose
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. All preferreds must be
tried.
Preferred drugs must be tried and failed, in step-order, due to lack of efficacy (failure to reach target IOP reduction) or intolerable side effects before non-preferred drugs will be
approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
significant potential drug interaction between another drug and the preferred drug(s) exists.
MC/DEL
ARTIFICIAL TEARS OINT
MC/DEL
MC/DEL
ARTIFICIAL TEARS SOLN OP
ARTIFICIAL TEARS SOLN
MC
BION TEARS SOLN
MC
CELLUVISC SOLN
MC
DRY EYES OINT
MC
EYE LUBRICANT OINT
MC
DURATEARS OINT
MC/DEL
GENTEAL
MC/DEL
HYPO TEARS
MC
LIQUITEARS SOLN
MC/DEL
ISOPTO TEARS SOLN
MC
MAJOR TEARS SOLN
MC
LACRI-LUBE
MC
PURALUBE OINT
MC
LUBRIFRESH P.M. OINT
MC
PURALUBE TEARS SOLN
MC
MURINE SOLN
MC
REFRESH SOLN OP
MC/DEL
MUROCEL SOLN
MC
REFRESH PLUS SOLN1
REFRESH PM OINT
MC/DEL
NATURE'S TEARS SOLN
MC
MC
REFRESH SOLN
MC
MC
REFRESH TEARS SOLN1
SYSTANE
MC
TEARGEN SOLN
MC
TEARISOL SOLN
MC/DEL
TEARS NATURALE
MC/DEL
TEARS PURE SOLN
TEARS RENEWED OINT
MC
THERATEARS SOLN
MC/DEL
OP. - BETA - BLOCKERS
OP. - ANTI-INFLAMMATORY / STEROIDS
OPHTH.
MC
V-R ARTIFICIAL TEARS SOLN
MC
BETAGAN SOLN
MC/DEL
BETOPTIC-S SUSP
MC/DEL
CARTEOLOL HCL SOLN
MC/DEL
BETAXOLOL HCL SOLN
MC/DEL
LEVOBUNOLOL HCL SOLN
MC/DEL
BETIMOL SOLN
MC/DEL
METIPRANOLOL SOLN
MC/DEL
TIMOLOL MALEATE SOLG (GEL)
MC/DEL
TIMOLOL MALEATE SOLN
MC
MC/DEL
MC
MC
ISTALOL
OCUPRESS SOLN
MC/DEL
MC
OPTIPRANOLOL SOLN
MC/DEL
TIMOPTIC SOLN
MC/DEL
TIMOPTIC-XE SOLG
AK-SPORE HC OINT
MC
AK-TROL SUSP
ALREX SUSP
MC
BAC/POLY/NEOMY/HC OINT
BLEPHAMIDE SUSP
MC
BLEPHAMIDE S.O.P. OINT
MC/DEL
DEXAMETH SOD PHOS SOLN
MC
BROMDAY
MC/DEL
FLAREX SUSP
MC
EFLONE SUSP
MC/DEL
FLUOROMETHOLONE SUSP
MC
FLUOR-OP SUSP
MC/DEL
LOTEMAX SUSP
MC
FML S.O.P. OINT
MC
MAXITROL OPTH OINT 0.1%
MC
PRED MILD SUSP
MC/DEL
NEOM/POLY/DEX OPTH OINT 0.1%
MC/DEL
PREDNISOLONE
MC/DEL
OZURDEX
MC/DEL
TOBRADEX OINT
MC
PRED FORTE SUSP
MC/DEL
TOBRADEX ST
MC
PRED-G SUSP
MC/DEL
LOTEMAX GEL
MC
PRED-G S.O.P. OINT
MC/DEL
LOTEMAX OINT
MC/DEL
SULFACET SOD/PRED SOLN
MC/DEL
TOBRADEX SUSP
MC/DEL
TOBRAMYCIN SUSP DEXAMETHASONE
MC
NEO/POLY/BAC/HC OINT
MC
VASOCIDIN SOLN
MC/DEL
OP. - PROSTAGLANDINS
MC/DEL
LATANOPROST SOL 0.005%
MC/DEL
TRAVATAN-Z
VEXOL SUSP
MC/DEL
7
ZIOPTAN
MC
8
LUMIGAN SOLN1
Page 48 of 58
MC
8
RESCULA
MC/DEL
8
TRAVATAN SOLN
MC/DEL
MC/DEL
8
8
TRAVOPROST
2. Dosing limits apply,
please see dosing
consolidation list.
1,2,3
XALATAN SOLN
1
Preferred drugs must be tried and failed, in step-order, due to lack of efficacy (failure to reach target IOP reduction) or intolerable side effects before non-preferred drugs will be
approved, unless an acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a
significant potential drug interaction between another drug and the preferred drug(s) exists.
3. Clinical PA is required to
establish diagnosis and
medical necessity.
Use PA Form# 20420
OP. - CYCLOPLEGICS
OP. - MIOTICS - DIRECT ACTING
MC
ATROPINE SULFATE
MC/DEL
CYCLOPENTOLATE HCL SOLN
MC/DEL
ISOPTO HYOSCINE SOLN
MC/DEL
ISOPTO CARBACHOL SOLN
MC
MC
OP. - ADRENERGIC AGENTS
OP. - SELECTIVE ALPHA ADRENERGIC
AGONISTS
AK-PENTOLATE SOLN
MC/DEL
CYCLOGYL SOLN
MC
MC/DEL
ISOPTO HOMATROPINE SOLN
MC
Use PA Form# 20420
PILOCAR SOLN
PILOCARPINE HCL SOLN
MC/DEL
PILOPINE HS GEL
MC/DEL
DIPIVEFRIN HCL SOLN
MC
PROPINE SOLN
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
ALPHAGAN P 0.15% SOLN
MC
ALPHAGAN SOLN
Use PA Form# 20420
SIMBRINZA
MC
ALPHAGAN P 0.1% SOLN
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
All preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is
offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug
and the preferred drug(s) exists.
MC
EPIFRIN SOLN
MC
BRIMONIDINE 0.2%
MC/DEL
OP. - NSAID'S
OP. - OF INTEREST
IOPIDINE SOLN
MC/DEL
PATADAY SOLN
MC
8
ALOCRIL SOLN
MC/DEL
PATANOL SOLN
MC/DEL
8
ALOMIDE SOLN
MC
8
BEPREVE
MC
8
ELESTAT
MC/DEL
8
EMADINE SOLN
MC
MC/DEL
8
LASTACAFT
8
OPTIVAR
MC
8
OPTICROM SOLN
MC/DEL
8
PAZEO
MC/DEL
8
ZADITOR SOLN
MC/DEL
9
EPINASTINE
OP. ANTI-ALLERGICS- MASTCELL
STABILIZER CLASS
OP. - CARBONIC ANHYDRASE
INHIBITORS/COMBO
MC/DEL
MC
MC/DEL
ALAMAST SOLN
Use PA Form# 20420
AZOPT SUSP
MC/DEL
COSOPT SOLN PF
Use PA Form# 20420
COMBIGAN
MC/DEL
TRUSOPT SOLN
MC/DEL
DORZOLAMIDE
MC/DEL
DORZOLAMIDE/TIMOLOL
MC
FLURBIPROFEN SODIUM SOLN
MC
8
ACULAR LS1
MC/DEL
DICLOFENAC OPTH 0.1%
MC
8
MC/DEL
KETOROLAC OPTH 0.4%
MC/DEL
8
ACULAR SOLN1
ILEVRO
MC/DEL
KETOROLAC OPTH 0.5%
MC/DEL
MC/DEL
8
8
PROLENSA
MC
8
OCUFEN SOLN1
MC
8
XIBROM1
MC
8
VOLTAREN SOLN1
MC
8
MC/DEL
9
ACUVAIL1
BROMFENAC
MC/DEL
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MUROCOLL-2 SOLN
MC/DEL
OP. - ANTI-ALLERGICS
Use PA Form# 20420
ISOPTO ATROPINE SOLN
ISOPTO CARPINE SOLN
MC/DEL
MC/DEL
MC/DEL
ENUCLENE SOLN
1. Must fail all preferred
products before nonpreferred.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
NEVANAC1
MC
BOTOX SOLR
MC
RESTASIS1
Use PA Form# 20420
1. Must have kerato
Must fail adequate trials of multi agents from artificial tears and lubricant category.
conjuctivitus sicca and failed
other dry eye therapies.
Use PA Form# 20420
Page 49 of 58
DERMATOLOGICAL
TOPICAL - ORAL
MC
AMNESTEEM
MC
CLARAVIS
1
SOTRET
MC
TOPICAL - ACNE PREPARATIONS
MC
MC
MC/DEL
1. Users 24 or under, PA
will not be required.
1
1
Use PA Form# 20420
AZELEX CREA4
BENZOYL PEROXIDE
ADAPALENE 0.3% GEL
ACZONE
1. Users 24 or under, PA
will not be required.
MC
ALTINAC CREA
MC
AVITA CREA
MC
BENZAC
2. Dosing limits allowing
one package per month.
Please refer to Dose
Consolidation List.
MC/DEL
MC
MC/DEL
CLINDAMYCIN PHOSPHATE 2
ERYDERM SOLN
ERYTHROMYCIN GEL
MC/DEL
ERYTHROMYCIN PADS
MC/DEL
MC/DEL
ERYTHROMYCIN SOLN
MC/DEL
BENZACLIN GEL
BENZAGEL-10 GEL
MC
ISOTRETINOIN
MC/DEL
BENZAMYCIN GEL
MC
METRONIDAZOLE CREA
MC/DEL
BENZAMYCINPAK PACK
MC
METRONIDAZOLE GEL2
MC
METRONIDAZOLE LOTN
SODIUM SULFACET/SULF LOTN
MC
MC/DEL
MC
MC/DEL
MC
2
2
3
MC
BENZEFOAM
MC
BREVOXYL
MC/DEL
TAZORAC
MC
CLEOCIN-T2
CLINAC BPO GEL
TRETINOIN GEL1
TRETINOIN CREA1,2
MC
CLINDAGEL GEL
MC
CLINDETS SWAB
MC
DESQUAM-E GEL
MC
DESQUAM-X
MC
DIFFERIN 0.3% GEL
MC
DIFFERIN
MC
DUAC GEL
MC
EMGEL GEL
MC
EPIDUO
MC
ERYCETTE PADS
MC/DEL
FINEVIN CREA
MC/DEL
MC
KLARON LOTN
METROGEL GEL2
MC
METROLOTION LOTN2
NEOBENZ MICRO
MC
SOOLANTRA4
TRIAZ
MC/DEL
TOPICAL - ANTIFUNGALS
MC
VELTIN
MC
ZENCIA WASH
MC
ZETACET
MC/DEL
ZIANA
BACIT/NEOMYCIN/POLYM OINT
MC/DEL
MC/DEL
BACITRACIN OINT
MC/DEL
ALTABAX 1
BACTROBAN OINT.
MC/DEL
BACTROBAN CREA1
BACTROBAN NASAL OINT
MC/DEL
TRIPLE ANTIBIOTIC OINT
CENTANY OINT 2% 1
GENTAMICIN SULFATE
MC/DEL
MUPIROCIN1
MC/DEL
MC
BETAMETHASONE CLOTRIMAZOLE LOT
CICLOPIROX 0.77 CREA
MC
MC/DEL
CICLOPIROX 0.77 SUSP
CLOTRIMAZOLE
Use PA Form# 20420 for all
other requests
RETIN-A CREA2
RETIN-A MICRO GEL
MC
MC/DEL
Use PA Form# 10220 for
Brand Name requests
ONEXTON5
RETIN-A GEL2
MC
MC
MC/DEL
5. Not approved for use in
children <12 years of age
NORITATE CREA
MC
MC/DEL
4. Dosing limits apply,
please see dosing
consolidation list.
METROCREAM CREA2
MC
MC/DEL
MC
3. Only available if
component ingredients are
unavailable.
EVOCLIN
MC
MC
TOPICAL - ANTIBIOTIC
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Dosing limits apply,
please see dosing
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
MC/DEL
8
BETAMETHASONE CLOTRIMAZOLE CREA
MC/DEL
MC
8
8
CICLOPIROX SOLN
EXELDERM
MC
8
FUNGIZONE CREA
Use PA Form# 10120
1. Diagnosis required
Page 50 of 58
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
ECONAZOLE NITRATE CREA
KETOCONAZOLE CREA
MC/DEL
8
HYDROCORT/IODOQ CREA
MC/DEL
MC
MC
8
MC/DEL
MC/DEL
KETOCONAZOLE SHAM
LOPROX 1.0 CREA
MC
MC/DEL
8
JUBLIA
1
KERYDIN
8
LAMISIL
MC/DEL
LOPROX 1.O LOTN
MC/DEL
8
LOPROX 0.77 LOTN
MC/DEL
LOPROX GEL
MC/DEL
8
LOPROX 0.77 CREA
MC/DEL
LOPROX TS LOTN
MC/DEL
8
LOPROX 0.77 SUSP
MC/DEL
LOTRISONE CREA
MC/DEL
8
LOPROX SHAMPOO SHAM
MC/DEL
MICONAZOLE NITRATE CREA
MC
MYCO-TRIACET II CREA
MC
8
LOTRIMIN
MC/DEL
8
LOTRISONE LOT
MC
8
LUZU
MC/DEL
8
MENTAX CREA
MC/DEL
NYSTATIN
MC/DEL
NYSTATIN/TRIAMCINOLONE CREA
MC/DEL
NYSTOP POWD
MC
8
MYCOGEN II CREA
MC
MC/DEL
PEDI-DRI POWD
MC
8
NAFTIN
TINACTIN
MC
8
NIZORAL SHAM
MC/DEL
MC
8
8
NYSTATIN/TRIAMCINOLONE OINT
MC/DEL
8
OXISTAT
MC/DEL
9
PENLAC NAIL LACQUER SOLN
MC
TOPICAL - ANTIPRURITICS
MC
TOPICAL - ANTIPSORIATICS
MC/DEL
TRI-STATIN II CREA
DDI: Ketoconazole will now be non-preferred and require prior authorization if they are currently being used in combination with any of the following medications: Prevacid,
pantoprazole, Onglyza or Omeprazole.
Kerydin- Verify prior trials and failures or intolerance of preferred treatments, including both topical and oral agents
NYSTAT-RX POWD
ZONALON CREA
MC
PRUDOXIN CREA
SORIATANE CAPS
MC
OXSORALEN ULTRA CAPS1
TAZORAC
MC
PSORIATEC CREA1
MC/DEL
SORIATANE CK KIT1
MC/DEL
MC
TACLONEX1,2
Use PA Form# 20420
MC
VECTICAL1
1. Must fail all preferred
products before nonpreferred.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Individual ingredients are
available as preferred witout
PA.
Use PA Form# 20420
TOPICAL - ANTISEBORRHEICS
MC/DEL
SELENIUM SULFIDE SHAM
TOPICAL - ANTIVIRALS
MC
CARMOL SCALP TREATMENT KIT
MC
ZNP BAR
MC/DEL
DENAVIR CREA1, 3
MC
ZOVIRAX OINT1,2
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
1. Must fail oral treatment
with Acyclovir or
Valacyclovir.
2. Approvals limited to 1
tube per 180 days.
3. Dosing limits apply,
please see dosing
consolidation list.
Use PA Form# 20420
TOPICAL - ANTINEOPLASTICS
TOPICAL - BURN PRODUCTS
MC
EFUDEX
MC/DEL
CARAC CREA
MC
FLUOROPLEX CREA
MC/DEL
FLUOROURACIL
MC
SOLARAZE GEL
MC
MC/DEL
MC
MC
MC/DEL
TOPICAL - CORTICOSTEROIDS
FURACIN CREA
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC/DEL
ZYCLARA
MC/DEL
SILVADENE CREA
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC/DEL
At least 1 drug from each potency of preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an
acceptable clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug
interaction between another drug and the preferred drug(s) exists.
SILVER SULFADIAZINE CREA
SSD AF CREA
SSD CREA
THERMAZENE CREA
LOW POTENCY
ACLOVATE
Use PA Form# 20420
MC
AMCINONIDE CREA
MC/DEL
DESOWEN1
HYDROCORTISONE CREA
MC
ANUSOL HC-1 OINT
MC
HYDROCORTISONE LOTN
MC/DEL
1. Dosing limits apply,
please see dosing
consolidation list.
MC
LACTICARE-HC LOTN
MC
NUTRACORT LOTN
MC/DEL
CORDRAN
MC
TEXACORT SOLN
MC/DEL
CORMAX
MC
MC
CLOBETASOL PROPINATE LOTN
CLODERM CREA
Page 51 of 58
MEDIUM POTENCY
MC/DEL
DESOXIMETASONE .05%
MC/DEL
ELOCON
MC/DEL
FLUOCINOLONE ACETONIDE .025-.01%
MC/DEL
CUTIVATE CREA / OINT
MC/DEL
CUTIVATE LOTN
MC
DERMA-SMOOTHE/FS OIL
MC/DEL
DERMATOP
MC
DESONATE GEL
MC
FLUROSYN CREA
MC
FLUTICASONE PROPIONATE CREA/OINT
MC
ELOCON OINT
MC
HYDROCORTISONE BUTYRATE
MC
HYDROCORTISONE POWD
MC
HYDROCORTISONE OINT
MC
KENALOG AERS
MC
HYDROCORTISONE VALERATE
MC
LIDA MANTLE HC CREA
MC
MOMETASONE FUROATE OINT
MC/DEL
LOCOID
TRIAMCINOLONE ACETONIDE .025-.1%
MC/DEL
LUXIQ FOAM
MC/DEL
OLUX FOAM
MC/DEL
HIGH POTENCY
MC/DEL
BETAMETHASONE DIPROPIONATE
MC
MC/DEL
CLOBEX LOTN
DESOXIMETASONE .25%
MC/DEL
MC/DEL
DESONIDE
FLUOCINOLONE ACETONIDE .02%
MC/DEL
MC/DEL
DIPROLENE
MC
PANDEL CREA
MC
PROCTOCORT CREA
MC/DEL
PSORCON
MC/DEL
PSORCON E
MC/DEL
TEMOVATE
MC
TOPICORT
FLUOCINONIDE
MC
TOPICORT LP CREA
MC
HALOG
MC
ULTRAVATE
MC
HALOG-E CREA
MC/DEL
1
MC/DEL
VERDESO
MC
WESTCORT
MC
EPIFOAM FOAM
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DERMA-SMOOTHE/FS ATOPIC P KIT
MC
CARMOL-HC CREA
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
AMMONIUM LACTATE CREA1
MC
MC
LAC-HYDRIN CREA1
LAC-HYDRIN LOTN 12%
Use PA Form# 20420
AMMONIUM LACTATE LOTN 12% 1
VITAMIN A & D MEDICATED OINT
MC
MEDERMA GEL
MC
MIMYX
MC
RENOVA CREA
1. Dosing limits still apply.
Please see dose
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MC
CARMOL 40 CREA
MC
SALEX CREA
MC
SALEX LOTN
TRIAMCINOLONE ACETONIDE .5%
VERY HIGH POTENCY
MC/DEL
AUGMENTED BETA DIP
MC/DEL
BETAMETHASONE VALERATE
MC/DEL
BETA-VAL
MC
DIFLORASONE DIACETATE
MC
HALOBETASOL
MC
PROCTO-KIT CREA 1%
MISCELLANEOUS
TOPICAL - STEROID LOCAL
ANESTHETICS
TOPICAL - STEROID COMBINATIONS
TOPICAL - EMOLLIENTS
MC
MC/DEL
MC
MC
TOPICAL - ENZYMES / KERATOLYTICS /
UREA
MC
SANTYL OINT
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Ziox, Panafil and Papain products have been removed from the PDL due to FDA safety concerns regarding drugs containing Papain.
TOPICAL - GENITAL WARTS
MC/DEL
IMIQUIMOD2
MC/DEL
5
PODOFILOX SOLN
MC/DEL
8
8
ALDARA
8
8
PICATO
MC/DEL
MC
MC
CONDYLOX1
VEREGEN1
Use PA Form# 20420
1. Non-preferred products
must be used in specified
order.
2. Dosing limits still apply.
Please
Page 52
of see
58dose
consolidation list.
TOPICAL - IMMUNOMODULATORS
2. Dosing limits still apply.
Please see dose
consolidation list.
1
MC
8
ZYCLARA
MC/DEL
8
ELIDEL CREA1
MC
9
PROTOPIC OINT
1,2
Use PA Form# 20420
1. Non-preferred products
must be used in specified
order.
Preferred corticosteroids from other classes must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable
clinical exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction
between another drug and the preferred drug(s) exists. Approvals will be made for small amounts of non-preferred products for the treatment of very steroid-sensitive areas in
conjunction with topical steroids for the treatment of atopic dermatitis.
2. The FDA has issued a
Public Health Advisory for
both Elidel and Protopic
concerning the potential
cancer risk associated with
their use. Use for children
less than 2 years of age is
not recommended.
TOPICAL - LOCAL ANESTHETICS
MC
MC/DEL
MC
MC/DEL
MC/DEL
AF CAPSICUM OLEORESIN CREA
MC/DEL
EMLA PADS
CAPSAICIN CREA
MC/DEL
EMLA CREA
ELA-MAX1
MC
LIDA MANTLE CREA
LIDOCAINE/PRILOCAINE CREA1
LIDOCAINE GEL
MC
LIDODERM PTCH
MC
PONTOCAINE SOLN
MC
SYNERA
MC
ZOSTRIX
TOPICAL - DEPIGMENTING AGENTS
TOPICAL - SCABICIDES AND
PEDICULICIDES
MC
8
ALUSTRA CREA
MC
8
EPIQUIN MICRO
MC
8
GLYQUIN CREA
MC/DEL
8
HYDROQUINONE CREA
MC/DEL
8
HYDROQUINONE/SUNSCREENS
MC
8
SOLAQUIN FORTE CREA
MC
8
TRI-LUMA CREA
MC
9
ELDOQUIN
MC/DEL
1
ACTICIN CREA
MC
MC
1
LICE KILLING SHAM
MC
MC/DEL
1
LICE TREATMENT CREME RINS LIQD
MC/DEL
1
PERMETHRIN LOTN
MC
2
NATROBA
MC/DEL
MC
ELIMITE CREA
EURAX
LINDANE
MALATHION
OVIDE LOTN
1,2
1. Lidocaine/Prilocaine
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
cream and Ela-Max
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
products require PA for
preferred drug(s) exists.
users over 18 years of age.
Use PA Form# 20420
As per Medicaid Policy, cosmetic drugs are not covered. Non-cosmetic clinical applications will be considered by prior authorization on a case by case basis.
Use PA Form# 20420
Use PA Form# 20420
1. Dosing limits apply,
please refer to dosage
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
2. Will require two
applications of permethrin.
MC
TOPICAL - WOUND / DECUBITUS CARE
TOPICAL - ASTRINGENTS /
PROTECTANTS
TOPICAL - ANTISEPTICS /
DISINFECTANTS
MC
XERAC AC SOLN
MC
MC
SKLICE
ULESFIA
MC
REGRANEX GEL
MC/DEL
REGENECARE
MC/DEL
RADIAPLEXRX
MC
LOWILA BAR
MC
MOISTURIN DRY SKIN CREA
MC
PROSHIELD PLUS SKIN PROTE CREA
MC
SURGILUBE GEL
MC/DEL
PHISOHEX LIQD
MC
BETADINE OINT
MC/DEL
POVIDONE-IODINE SOLN
MC
FORMALYDE-10 AERS
MC
IODOSORB
MC
LAZERFORMALYDE SOLUTION SOLN
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists. Regranex will be approved for diabetic patients in good control (hgba1c <8), who are not smoking, with a stage III or IV WOCN AND NPUAP lower extremity
diabetic ulcer and with an adequate blood supply (Tcp 02 >30, ABI>0.7 or ASP> 70), and where the underlying cause has been corrected. The wound must be free of infection and
have been previously treated with preferred standard therapies for at least 2 months. Maximum approval for 20 weeks.
Accuzyme and Ethezyme products have been removed from the PDL due to FDA concerns regarding drugs containing Papain.
Use PA Form# 20420
1. Dosing limits apply,
please refer to dosage
consolidation list.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
MISCELLANEOUS EYE
OP. - EYE
MC
AK-DILATE SOLN
MC
MC
EYE WASH SOLN
MC/DEL
MC
NAPHAZOLINE HCL SOLN
MC
PHENYLEPHRINE HCL SOLN
MC
LENS PLUS REWETTING DROPS
MURO 128
NEO-SYNEPHRINE SOLN
Page 53 of 58
preferred drug(s) exists.
MC
PONTOCAINE SOLN
MC/DEL
SODIUM CHLORIDE
MC/DEL
A/B OTIC SOLN
MC
ANTIBIOTIC EAR SOLN
ACETASOL SOLN
MC
ANTIBIOTIC EAR SUSP
MC
COLY-MYCIN-S SUSP
MISCELLANEOUS EAR
EAR
MC
MC/DEL
MC/DEL
ACETASOL HC SOLN
ACETIC ACID
MC/DEL
CORTISPORIN-TC SUSP
MC/DEL
ACETIC ACID/HYDROCORTISON
MC/DEL
DEBROX SOLN
MC/DEL
ALLERGEN SOLN
MC
MC/DEL
MC/DEL
MC
MC/DEL
MC
CARBAMIDE PEROXIDE 6.5% OTIC SOLN.
MC/DEL
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
1. Must fail all preferred
products before nonpreferred.
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
DERMOTIC
OFLOXACIN 0.3% OTIC
CIPRODEX
CIPRO HC SUSP
CORTISPORIN SOLN
CORTOMYCIN
MC
EAR DROPS SOLN
MC
EAR DROPS RX SOLN
MC/DEL
EAR WAX REMOVAL DROPS
MC/DEL
NEOMYCIN/POLYMYXIN/HC
MOUTH ANTISEPTICS
MOUTH ANTI-INFECTIVES
MOUTH ANTISEPTICS
MC
NILSTAT SUSP
MC
MYCELEX TROC
MC/DEL
NYSTATIN SUSP
MC
ORAVIG
MC/DEL
CHLORHEXIDINE GLUCONATE
MC
APHTHASOL PSTE
MC/DEL
LIDOCAINE VISCOUS SOLN
MC
PERIOGARD SOLN
MC
TRIAMCINOLONE IN ORABASE PSTE
MC
TRIAMCINOLONE ACETONIDE PSTE1
MC
TRIAMCINOLONE ORADENT PSTE
1
1
DENTAL PRODUCTS
DENTAL PRODUCTS
MC/DEL
ETHEDENT CREA
MC0MC
APF GEL GEL
MC/DEL
GEL-KAM CONC
MC/DEL
DENTAGEL GEL
MC/DEL
GEL-KAM GEL 0.4%
MC/DEL
PHOS-FLUR GEL
MC/DEL
MC/DEL
PHOS FLUR SOLN
MC
MC/DEL
SF GEL
THERA-FLUR-N GEL
SF 5000 PLUS CREA
MC
STANNOUS FLUORIDE ORAL RI CONC
MC
SALIVA SUBSTITUTE SOLN
ARTIFICIAL SALIVA/STIMULANTS
ARTIFICIAL SALIVA/STIMULANTS
MC
EVOXAC CAPS
MC
RADIACARE SOLR
MC
SALAGEN TABS
MISCELLANEOUS ANORECTAL
ANORECTAL - MISC.
MC/DEL
COLOCORT ENEM
MC/DEL
ANUSOL-HC CREA
MC
CORTENEMA ENEM
MC/DEL
CORTIFOAM FOAM
MC
ELA-MAX 5 CREA
MC/DEL
PROCTOFOAM HC FOAM
MC/DEL
MC/DEL
HYDROCORTISONE ENEM
MC/DEL
PROCTO-KIT CREA 2.5%
MC/DEL
PROCTOZONE-HC CREA
PROCTOSOL HC CREA
MC
Use PA Form# 20420
RECTIV OINT
T-CELL ACTIVATION INHIBITOR
PSORIASIS BIOLOGICALS
MC
COSENTYX3
MC
OTEZLA
1. Will not require a PA if at Approved for severe chronic plaque psoriasis unresponsive to first line therapies. A trial of at least several potent topicals from the following categories: corticosteroids, coal tars,
anthralin, calcipotriene and tazorotene, and at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin and phototherapy/UVA.
such as methotrexate,
Page 54
leastof
one58
systemic drug
MC
MC
ENBREL
1,2
MC
1. Will not require a PA if at Approved for severe chronic plaque psoriasis unresponsive to first line therapies. A trial of at least several potent topicals from the following categories: corticosteroids, coal tars,
least one systemic drug
anthralin, calcipotriene and tazorotene, and at least one systemic drug such as methotrexate, cyclosporine, methoxsalen or acitretin and phototherapy/UVA.
such as methotrexate,
cyclosporine, methoxsalen
or acitretin is in members
drug profile. Please refer to
dose consolidation list.
STELARA
1
HUMIRA
Enbrel is preferred after a trial of a step 1 product (e.g. azathioprine, methotrexate, etc.); however, dosing limits will also still apply. Dosing limits will allow 8 injections per month without
pa. Use of greater than 8 injections per month will require PA. In addition, the preferred Enbrel 25mg product will be the multi-dose vial (NDC- 58406-0425-34). The single-use prefilled
syringes are non-preferred.
2. Preferred dosage form
allowed without PA after trial
of step 1 prodcuts is multidose vial, with dosing limits
allowing 8 injections per 28
days without pa.
3. Will be preferred for the
indication of plaque
psoriasis only after trail and
failure of Humira.
Use PA Form# 20910
ALTERNATIVE MEDICINES
ALTERNATIVE MEDICINES
MC
DIMETHYL SULFOXIDE SOLN
MC/DEL
CO-ENZYME Q-10
MC
MELATONIN TABS
Use PA Form# 20420
Will only be approved for specific conditions supported by at least two double-blinded, placebo-controlled randomized trials that are not contradicted by other studies of similar quality.
CHELATING AGENTS
CHELATING AGENTS
MC/DEL
CUPRIMINE CAPS
MC
MC/DEL
DEPEN TITRATABS TABS
EXJADE1
Use PA Form# 20420
1. FDA indication of
treatment of chronic iron
ovrload due to blood
transfustions in membes 2
years of age and older is
requried for approval of
Exjade.
ANTILEPROTIC
ANTILEPROTIC
MC
1
THALOMID CAPS
1. All PA requests for
Approved for indications of leprosy, treatment-resistant multiple myeloma and AIDS.
150mg dosing will require
use of Thalomid 100mg and
50mg capsules.
Use PA Form# 20420
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS ANTIADNDROGENS
ANTINEOPLASTIC AGENTS- LHRH
ANALOGS
MC/DEL
BICALUTAMIDE
MC/DEL
CASODEX
MC
VANTAS2
MC
FIRMAGON2
TRELSTAR
Use PA Form# 20420
MC
LUPRON DEPOT1
MC/DEL
1. Dosing limits apply,
please refer to dosage
consolidation list.
2. PA required to confirm
FDA approved indication.
Use PA Form# 20420
ANTINEOPLASTIC AGENTS - TYROSINE
KINASE INHIBITORS
MC
SPRYCEL1
MC/DEL
TYKERB2
MC
GLEEVEC1
Use PA Form# 20420
1. Verification of diagnosis
is required.
Page 55 of 58
KINASE INHIBITORS
2. PA required to confirm
FDA approved indication
and to monitor for potential
drug-drug interactions.
ANTINEOPLASTICS-MISCELLANEOUS
MC
MC/DEL
MC
AMIFOSTINE
MC/DEL
MERCAPTOPURINE
ANTINEOPLASTICS- MONOCLONAL
ANTIBODIES
DOCEFREZ
Use PA Form# 20420
ETHYOL
MC
LEUPROLIDE
MC/DEL
OXALIPLATIN
MC/DEL
PURINETHOL
MC/DEL
ZOLINZA
MC/DEL
HERCEPTIN1
1. PA required to confirm
FDA approved indication.
Use PA Form# 20420
CANCER
CANCER
MC
ALIMTA
1. PA required to confirm
FDA approved indication
MC/DEL
ANASTROZOLE TABS
MC
MC/DEL
ALECENSA
ARIMIDEX
MC/DEL
AVASTIN
MC/DEL
BOSULIF
MC
ERBITUX
MC
COMETRIQ
MC/DEL
LETROZOLE
MC
MC
MC/DEL
MEGACE ES
VIDAZA
MC/DEL
MC/DEL
COTELLIC
EMPLICITI(IV)8
MC
MC
3,4,5
ERIVEDGE
FARYDAK
MC/DEL
FOLOTYN
GILOTRIF4,5
MC/DEL
MC
IBRANCE
ICLUSIG3
IMLYGIC
MC/DEL
MC
MC/DEL
MC
LENVIMA
MC
LONSURF
LYNPARZA7
MC
NEXAVAR1
NINLARO(PO)
MC/DEL
MC
MC
MC/DEL
MC/DEL
2. Avoid CYP3AY drug drug
Xalkori will be considered for patients with a diagnosis of locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK)-positive as
interaction.
detected by an FDA- approved test (please included a copy of test results; and is prescribed by an oncologist; quantity limit of 60 tablets per 30 days.
3. Clinical PA required for
appropriate diagnosis
MEKINIST3,4
ODOMZO1,2,5
POMALYST
STIVARGA
MC/DEL
SUTENT1,2
SYLATRON
MC/DEL
TAFINLAR3,4,5,6
MC/DEL
TAGRISSO
FEMARA
MC/DEL
YERVOY
MC/DEL
XALKORI
MC/DEL
XTANDI
MC/DEL
ZELBORAF
MC
ZYDELIG
MC/DEL
MC
ZYKADIA
Zelboraf will be considered for patients 18 years of age or older; has a diagnosis of unresectable or metastatic melanoma with BRAF mutation as detected be an FDA-approved test;
prescriber is an oncologist with a quantity limit of 240 tablets per 30 days.
4. Re-approval will require Bosulif requires a clinical PA, requiring diagnosis. Must have resistance or intolerance to prior therapy (such as imatinib [Gleevec®] or a TKI) seen in drug profile, monthly heptic
documentation of response enzyme tests should be preformed for the first three months of treatment , as clinically indicated.
without disease progression
Iclusig requires prior trail of TKI therapy, appropriate monitoring and has DDI with strong CYP3A4 inducers
and tolerance to treatment
INLYTA
JAKAFI
KEYTRUDA7
A clinical PA is required for Inlyta to verify diagnosis and failure of one prior systemic therapies
5. Dosing limits apply,
please see dosage
consolidation list.
Stivarga is non-preferred and is for the treatment of metastatic colorectal cancer (CRC) who have been previously treated with fluoropyrimidine- oxaliplatin- and irinotecan-based
chemotherapy, an anti-VEGF therapy, and if KRAS wild type, an anti-EGFR therapy).The safety and efficacy of use in children under the age of 18 years have not been established.
DDI: Cometriq, Ibrance and Tafinlar will require a prior authorization if it is currently being used in combination with drugs known to be significant CYP3A4 inhibitors (ketoconazole,
itraconazole, clarithromycin, indinavir, nefazodone, nelfinavir, ritonavir, atazanavir, saquinavir and telithromycin).
Gilotrif needs to be prescribed by an oncologist
6. Max daily dose of 300mg.
Xtandi is non-preferred and is limited to adults treatment of metastatic castration-resistant prostate cancer, with previous trials of docetaxel.
7. PA required to confirm
FDA approved indication
8. Monitor liver enzymes
periodically and stop
treatment upon Grade 3 or
higher elevation of liver
enzymes approved
indication
Pomalyst has a DDI with strong inhibitors of CYP1A2 and CYP3A4 drugs. Complete blood counts weelky for first 8 weeks, then monthly, patients have at least 2 prior therapies,
including lenalidomide and bortezomib,female patients of reproductive potential must have 2 negative pregnancy tests and use 2 forms of contraception and providers must be certified
with Pomalyst REMS Program.
DDI: Strong and moderate CYP3A inhibitors and Strong and moderate CYP3A inducers should be avoided with use of Lynparza
Clinical PA required for Ibrance to verify diagnosis and concomitant use with letrozole
Use PA Form# 20420
Farydak in combination with bortezomib and dexamethasone for the treatment of patients with multiple myeloma (MM) who have received ≥2 prior regimens, including bortezomib and
an immunomodulatory agent
DDI: Strong or moderate CYP3A inhibitors and strong or moderate CYP3A inducers (carbamazepine, efavirenz, phenytoin, rifampin and St. John’s Wort) should be avoided with use of
Cotellic
DDI: Acyclovir/other antiherpetic viral agents may interfere with the effectiveness of Imlygic
ZYTIGA
Ninlaro: prior to starting a new cycle of therapy, it is recommended that: the absolute neutrophil count be ≥ 1,000/ mm3, platelet count be ≥ 75,000/ mm3 and non-hematologic
toxicities be recovered to patient’s baseline condition or Grade 1 or lower
Page 56 of 58
Lonsurf: Complete blood cell count should be obtained prior to an on day 15 of each cycle
Cycle of Lonsurf should not be started until: absolute neutrophil count (ANC) is ≥ 1500/mm3 or febrile neutropenia is resolved; platelets are >75,00/ mm3; and Grade 3 or 4 nonhematological adverse reactions are resolved to Grade 0 or 1.
-Within a treatment cycle, withhold Lonsurf if: ANC <500/ mm3 or febrile neutropenia; platelets <50,000/ mm3; Grade 3 or 4 non-hematological adverse reactions
- After Recovery, resume Lonsurf after reducing the dose by 5mg/m2/dose from the previous dose if the following occurs: febrile neutropenia; uncomplicated Grade 4 neutropenia or
thrombocytopenia that results in >1 week delay in start of next cycle; or non-hematologic Grade 3 or Grade 4 adverse reaction except for Grade 3 nausea and/or vomiting controlled by
antiemetic therapy or Grade 3 diarrhea responsive to antidiarrheal medication
DDI: Avoid concomitant use of Tagrisso with strong CYP3A inhibitors, strong CYP3A inducers, drugs that are sensitive substrates of CYP3A, breast cancer resistance protein (BCRP),
or CYP1A2 with narrow therapeutic indices.
IMMUNOSUPPRESSANTS
IMMUNOSUPPRESSANTS
MC/DEL
CYCLOSPORINE MODIFIED
MC/DEL
CELLCEPT
GENGRAF CAPS
MC/DEL
CYCLOSPORINE CAPS
MC/DEL
MYCOPHENOLATE
MC/DEL
MC/DEL
MYFORTIC
CYCLOSPORINE SOL. MODIFIED
PROGRAF CAPS
MC/DEL
NEORAL
MC/DEL
RAPAMUNE
MC/DEL
SANDIMMUNE
MC
MC
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
Use PA Form# 20420
DDI: Cyclosporine will now be non-preferred and require prior authorization if it is currently being used in combination with either Lipitor (doses greater than 20mg/day), Crestor, or
lovastatin (doses greater than 20mg).
DDI: Cyclosporine will require prior authorization when used with Livalo.
TACROLIMUS
DDI: All preferred immunosuppressants will require clinical PA for patients over 60 that are currently on fluoroquinolone therapy.
PURINE ANALOG
PURINE ANALOG
MC
MC/DEL
AZASAN TABS
MC/DEL
AZATHIOPRINE TABS
MC/DEL
KAYEXALATE POWD
IMURAN TABS
Use PA Form# 20420
Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical exception is offered
on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.
K REMOVING RESINS
K REMOVING RESINS
MC
Use PA Form# 20420
KIONEX POWD
MC/DEL
SODIUM POLYSTYRENE SULFON
MC/DEL
SPS SUSP
MC/DEL
SPS 30GM/120ML ENEMA SUSP
New drugs are initially non-preferred until reviewed by the DUR Committee and the State. According to State policy, any drug requiring specific diagnosis still requires the specific diagnosis unless otherwise noted within this document.
Page 57 of 58
ANTI-CONVULSANTS INDICATION CHART
SEIZURES
POST
HERPETIC
NEURALGIA
DIABETIC
PERIPHERAL
NEUROPATHY
MONOTHERAPY
BIPOLAR
ADJUNCTIVE
BIPOLAR
GABITRIL
X
9
8
LAMICTAL
X
4
4
LYRICA
X
TOPAMAX
X
9
6
TRILEPTAL
X
5
5
X(2nd line)
MIGRAINE
PROPHYLAXIS
X(2nd line)
FIBROMYALGIA
X(2nd line)
X (2nd line)
PEDIATRIC ANTI-CONVULSANTS INDICATION CHART
SEIZURES MONOTHERAPY BIPOLAR
LITHIUM
ADJUNCTIVE BIPOLAR
1
1
CARBMAZEPINE
X
1
1
VALPROATE
X
1
1
ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE
X
1
1
LAMICTAL
X
1
1
TRILEPTAL
X
5
5
CLOZAPINE
X
6
6
Page 58 of 58